The effects of lower eyelid epiblepharon surgery on the meibomian glands

The effects of lower eyelid epiblepharon surgery on the meibomian glands | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The effects of lower eyelid epiblepharon surgery on the meibomian glands Seongmi Kim, Da Eun Yoon, Namju Kim, Hyun Sun Jeon This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4469670/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Mar, 2025 Read the published version in BMC Ophthalmology → Version 1 posted 4 You are reading this latest preprint version Abstract Background To investigate the morphological and functional changes of meibomian glands (MG) in pediatric patients who underwent surgery for lower eyelid epiblepharon. Methods A total of 176 eyes of 88 patients aged 19 and under (mean age: 8.9 ± 2.8 years old) who underwent bilateral lower eyelid epiblepharon correction surgery from May 2022 to April 2023 were included. Meibograde, lipid layer thickness (LLT), total blink rate, and corneal/refractive astigmatism were compared between pre- and 2 months postoperatively. Results There were no statistically significant changes in meibograde and LLT after surgery. The total blink rate was significantly decreased after surgery ( p = 0.02). While corneal and refractive astigmatism showed no significant changes in total eyes, corneal astigmatism in eyes of high astigmatism of 2.0D or more subgroup exhibited a significant decrease postoperatively ( p < 0.001). Conclusions Lower eyelid epiblepharon surgery in pediatric patients does not significantly alter the structure and function of the MG. Additionally, stabilizing the ocular surface through surgical correction may have beneficial effects on blink rate and corneal astigmatism. Although the long-term evaluation would be needed, we suggest that lower eyelid epiblepharon surgery could be performed without worrying about adverse effects on the MG. Meibomian gland Epiblepharon Meibography Astigmatism Figures Figure 1 Figure 2 Background Epiblepharon is a common eyelid condition characterized by horizontal skin folds that may extend over the eyelid margin, causing the eyelashes to touch the corneal surface 1 . This condition is frequently observed in both lower eyelids of East Asian children and is traditionally managed through surgical intervention 2 , 3 . The corrective surgical procedure for lower eyelid epiblepharon involves suturing the subcutaneous tissue of the upper skin edge and the lower margin of the tarsus to achieve outward rotation of the eyelashes 4 . However, concerns have been raised regarding the potential impact of this surgical procedure on meibomian glands (MG) located within the tarsus. The MG, which is located within the tarsal plate of both the upper and lower eyelids, plays a crucial role in maintaining tear film stability and overall ocular surface health. A previous study by Christoph et al. 5 demonstrated an improvement in MG function after the implementation of a lateral canthal sling procedure in patients with age-related lid laxity. Conversely, Vaidya et al. 6 examined changes in MG function following eyelid corrective surgery in patients with involutional entropion and concluded that there were no significant postoperative alterations in MG function. However, there is a significant gap in our understanding of how morphology or function of MG are affected after surgical correction of the lower eyelid epiblepharon, as no study has specifically addressed this issue. Therefore, the primary objective of this study is to assess and compare morphological and functional changes of MG in pediatric patients who underwent surgery for lower eyelid epiblepharon, using the LipiView®II ocular surface interferometer. Methods Population This retrospective study was approved by the Institutional Review Board of the Seoul National University Bundang Hospital (IRB No. B-2401-875-106), and adhered to the tenets of the Declaration of Helsinki. The study included patients aged 19 and under who underwent lower eyelid epiblepharon surgery at Seoul National University Bundang Hospital from May 2022 to April 2023. Surgical indications for congenital lower eyelid epiblepharon were significant irritation symptoms and corneal erosions matching the extent of the epiblepharon. All patients underwent surgical correction of bilateral lower eyelid epiblepharon. Informed consent for surgical procedures was obtained from the parents of all patients. All surgeries were performed by a single experienced oculoplastic surgeon (NK) using the rotating suture technique. Patients with a history of congenital diseases, those concurrently afflicted with other ophthalmic conditions, and those undergoing collaborative surgery involving additional ophthalmic procedures were excluded from the study. Additionally, eyes with unreliable measurements due to inadequate data quality in both preoperative and postoperative examinations as well as cases lost to follow-up were excluded from the analyses (Fig. 1 ). Surgical Technique A subciliary skin incision line was marked horizontally from the temporal point of the inferior punctum along the entire lid length, 1 mm below the ciliary line. Local infiltration of 2% lidocaine mixed with epinephrine at a ratio of 1:100,000 was given subcutaneously along the marked line. Following skin preparation, the upper eyelid was retracted superiorly to avoid obscuring the margin of the lower lid by the cilia of the upper lid. The subciliary skin was incised along the previous mark with a No.15 scalpel blade, while the lid was held using chalazion forceps. The chalazion forceps were removed and dissection was performed inferiorly between the orbicularis muscle and tarsus using monopolar cautery until the lower margin of the tarsus was exposed. The pretarsal orbicularis oculi muscle remaining beneath the upper edge of the skin incision was excised using Westcott scissors until the tarsal plate was more exposed. The subcutaneous tissue at the upper edge of the incised subciliary skin was fixed to the lower margin of the tarsus using five to seven interrupted 8–0 nylon sutures to ensure outward eversion of the cilia. The lower edge of the incised skin was lifted to overlap the upper skin edge. A line was drawn on the overlapping lower skin to match the upper skin wound edge under it, and the redundant tissue was excised using Stevens' scissors. The skin was closed continuously with 5–0 rapid vicryl in young patients and with 6–0 black silk in patients older than 10 years of age. At the conclusion of the procedure, a small amount of antibiotic ointment was applied to the skin wound, and cold compressions were applied for the first 12 hours postoperatively. Data Collection Patient demographic information, including age and sex, was also obtained. Patient data were collected before surgery and at 2 months postoperatively. The outcome measures included meibography, lipid layer thickness (LLT), total blink rate, corneal astigmatism, and refractive astigmatism. Meibography, LLT, and total blink rate were measured using a LipiView®II ocular surface interferometer (TearScience Inc, Morrisville, NC, USA). Corneal astigmatism was measured using an OPD-Scan III (Nidek Technologies, Gamagori, Japan) and refractive astigmatism was measured using a KR-800A (Topcon, Tokyo, Japan). Grading of Meibomian Gland Dropout As we included patients who underwent epiblepharon surgery on both lower eyelids, the assessment of the meibograde was concentrated exclusively on the lower lid. The grading system for partial or complete loss of the MG in the lower eyelid included the following four categories: grade 0 (no loss of the MG); grade 1 (area loss comprising less than one-third of the total MG area); grade 2 (area loss ranging from one-third to two-thirds); and grade 3 (area loss exceeding two-thirds) 7 . Statistical Analysis IBM SPSS version 27.0 (IBM Corp., Armonk, NY, USA) was used for the statistical analyses. A paired t-test was performed to compare the preoperative and postoperative values, and quantitative variables were presented as mean and standard deviation (SD). A p -value of less than 0.05 was considered statistically significant. Results Of the 109 patients who underwent epiblepharon surgeries, 21 were excluded based on the following exclusion criteria: two had congenital diseases, one had a concurrent ophthalmic disorder, and 18 had collaboration with strabismus surgery. Finally, 176 eyes of 88 patients (mean age: 8.9 ± 2.8 years old, range 3 to 18 years) who met the inclusion criteria were included. Among them, meibography was available for 72 eyes of 36 patients (40.9%), total blink rate and LLT for 150 eyes of 75 patients (85.2%), and topography for 170 eyes of 85 patients (96.6%). There was no statistically significant difference between preoperative meibograde (0.31 ± 0.64) and postoperative meibograde (0.33 ± 0.65; p = 0.42, Table 1 ). Table 1 Change of clinical parameters after lower eyelid epiblepharon correction surgery Variable N (eyes) Preoperative Postoperative p -value Meibograde 72 0.31 ± 0.64 0.33 ± 0.65 0.42 Lipid layer thickness (nm) 150 66.30 ± 27.36 66.59 ± 24.83 0.91 Total blink rate 150 8.03 ± 5.04 6.85 ± 4.91 0.02 * Astigmatism (D) Corneal Astigmatism 170 1.95 ± 1.63 1.77 ± 1.47 0.20 Refractive Astigmatism 170 1.04 ± 1.04 1.05 ± 1.09 0.75 High Astigmatism (D) (Corneal Astigmatism ≥ 2.0D) Corneal Astigmatism 57 3.64 ± 1.77 2.41 ± 1.03 < 0.001 * Refractive Astigmatism 57 1.75 ± 1.36 1.83 ± 1.39 0.39 Low Astigmatism (D) (Corneal Astigmatism < 2.0D) Corneal Astigmatism 113 1.10 ± 0.49 1.44 ± 1.55 0.02 * Refractive Astigmatism 113 0.68 ± 0.56 0.66 ± 0.61 0.63 Values are presented as mean ± standard deviation. * Statistically significant differences between two groups ( p < 0.05) by paired t -test The LLT was not significantly different between preoperative (66.30 ± 27.36 nm) and postoperative measurements (66.59 ± 24.83, p = 0.91). However, the total blink rate was significantly decreased postoperatively (6.85 ± 4.91) compared to preoperatively (8.03 ± 5.04; p = 0.02, Table 1 ). In all eyes, there were no significant changes in corneal or refractive astigmatism after surgery. Mean corneal astigmatism was 1.95 ± 1.63 diopter (D) and 1.77 ± 1.47 D before and after surgery, respectively ( p = 0.20). Mean refractive astigmatism was 1.04 ± 1.04 D and 1.05 ± 1.09 D before and after surgery, respectively ( p = 0.75, Table 1 ). We conducted a subgroup analysis by categorizing eyes into two subgroups based on the level of corneal astigmatism: a “high astigmatism group (57 eyes from 57 patients)” with corneal astigmatism equal to or exceeding 2.0D and a “low astigmatism group (113 eyes from 67 patients)” with corneal astigmatism below 2.0D. In the “high astigmatism group,” the corneal astigmatism was significantly decreased after surgery from 3.64 ± 1.77D to 2.41 ± 1.03D ( p < 0.001, Fig. 2 ). However, in the “low astigmatism group,” the corneal astigmatism was significantly increased after surgery from 1.10 ± 0.49D to 1.44 ± 1.55D ( p = 0.02, Fig. 2 ). Regarding refractive astigmatism, there was no statistically significant difference observed in both the “high” and the “low” astigmatism groups ( p = 0.39 and p = 0.63, respectively) (Table 1 ). Discussion During the epiblepharon surgery, there is a postulation that it may influence the structure of the MG. However, there is currently a lack of research in this regard. This is the first study to evaluate the morphological and functional changes in the MG after epiblepharon surgery. Our study confirmed that there were no significant changes in the meibograde or LLT after surgery, indicating that lower eyelid epiblepharon surgery does not have a substantial short-term impact on the structure or function of the MG. In a healthy eyelid, the ductules of the MG contain keratohyalin granules, and their openings are located in front of the mucocutaneous junction. This positioning allowed for the direct delivery of meibum into the tear meniscus 8 . If epiblepharon surgery causes subtle structural changes in the MG, it could be hypothesized that it may potentially impact the function of the MG. Meibography is a widely used diagnostic imaging technique for meibomian gland dysfunction (MGD). This enables the objective and reproducible observation of MG 9 , 10 . While it is a short-term observation over a period of 2 months, our study is meaningful as the first report on the changes in MG by evaluating meibography following epiblepharon surgery, a procedure frequently performed in pediatric patients. LLT is considered an indicator that plays a role in preventing tear evaporation in patients with dry eye, although the standard has not been clearly established 11 . Additionally, it is regarded as one of the indicators for assessing the function of the MG 12 , 13 . Reduced LLT may be indicative of dry eye, and MGD is associated with their manifestations 12 – 15 . In a previous study, after the surgical correction of marginal entropion, repositioning of the MG ducts and orifices facilitated the release of pooled secretions, leading to an increase in LLT 16 . However, the results of this study indicated that there were no statistically significant changes in LLT after surgery. Considering that neither meibograde nor LLT showed postoperative changes, it can be inferred that, in the short term, surgery does not affect MG function. The blink patterns and rate are associated with tear breakup time (TBUT), and Ocular Surface Disease Index (OSDI) in dry eye disease 17 , 18 . Individuals with dry eyes tend to blink more frequently to improve the tear distribution on the ocular surface 19 . This increased blinking compensates for the reduced tear production and may be caused by discomfort on the ocular surface 20 . In this study, the total blink rate significantly decreased from 8.03 ± 5.04 before epiblepharon surgery to 6.85 ± 4.91 after surgery ( p = 0.02). The significant decrease in the blink rate after surgery may be related to the alleviation of discomfort from postoperative eyelash irritation. Additionally, this could be interpreted as a reduction in the compensatory mechanism due to a decrease in tear film instability. Astigmatism is also associated with epiblepharon. There have been conflicting reports regarding changes in astigmatism after surgery, with some studies suggesting a decrease, while others showing no significant difference 2 , 21 – 23 . In our study, corneal astigmatism significantly decreased by 1.23D only in the high astigmatism group, while it significantly increased by 0.34D in the low astigmatism group. The substantial change in corneal astigmatism observed in the high astigmatism group in our study aligns with the findings of Kim et al. 22 who observed a correlation between higher preoperative astigmatism levels and substantial postoperative changes in astigmatism. These results can also be interpreted as that corneal erosion caused by epiblepharon may impact the accuracy of topography, potentially normalizing evaluations that were previously overestimated or underestimated due to corneal erosion. There are several limitations in our study. First, the postoperative observational period was short by 2 months. However, we believe that this is enough to assess the structural impact associated with surgery. Second, owing to the pediatric nature of the patients, there were difficulties in obtaining cooperation during examinations, which could have impacted the quality of meibography, leading to the exclusion of some cases. However, we believe that the impact on the results was minimal, as we excluded cases with difficulty in cooperation or low-quality examinations from the analysis. Conclusions This study suggests that lower eyelid epiblepharon surgery in pediatric patients does not significantly alter the structure and function of the MG. Additionally, stabilizing the ocular surface through surgical correction may have beneficial effects on blink rate and astigmatism. When making surgical decisions, correction surgery for lower eyelid epiblepharon can be performed without worrying about adverse effects on the MG. Declarations Author contributions: Study design: HSJ, NK Writing the article: SK, DEY, HSJ, NK Data collection: SK, DEY Analysis and interpretation of the data: SK, DEY Literature search: SK, DEY, HSJ, NK Critical revision of the article: SK, DEY, HSJ, NK Final approval of the article: HSJ, NK Data availability No datasets were generated or analysed during the current study. Ethics declarations Ethics approval and consent to participate. This study was approved by the Institutional Review Board of the Seoul National University Bundang Hospital (IRB No. B-2401-875-106), and adhered to the tenets of the Declaration of Helsinki. Consent to publish Not applicable. Competing interests The authors declare no competing interests. Acknowledgments: None Funding None References Levitt JM. Epiblepharon and congenital entropion. Am J of Ophthalmol 1957;44(1):112-3. Shih MH, Huang FC. Astigmatism in children with epiblepharon. Cornea 2007;26(9):1090-4. Sundar G, Young SM, Tara S, Tan AM, Amrith S. Epiblepharon in East asian patients: the singapore experience. Ophthalmology 2010;117(1):184-9. Yang MK, Kim N, Choung HK, Khwarg SI. Effect of Congenital Lower Eyelid Epiblepharon Surgery on Asymmetric Margin Reflex Distance 1. Curr Eye Res 2021;46(7):954-960. Holtmann C, Finis D, Knop E, Borrelli M, Geerling G. Lateral Canthal Sling Procedure for Meibomian Gland Dysfunction? Results of a Pilot Study. Curr Eye Res 2021;46(10):1489-1494. Vaidya A, Kakizaki H, Takahashi Y. Postoperative changes in status of meibomian gland dysfunction in patients with involutional entropion. Int Ophthalmol 2020;40(6):1397-1402. Arita R, Itoh K, Inoue K, Amano S. Noncontact infrared meibography to document age-related changes of the meibomian glands in a normal population. Ophthalmology 2008;115(5):911-5. Knop E, Knop N, Zhivov A, et al. The lid wiper and muco-cutaneous junction anatomy of the human eyelid margins: an in vivo confocal and histological study. J Anat 2011;218(4):449-61. Arita R. Meibography: A Japanese Perspective. Invest Ophthalmol Vis Sci 2018;59(14):Des48-des55. Gulmez Sevim D, Gumus K, Unlu M. Reliable, Noncontact Imaging Tool for the Evaluation of Meibomian Gland Function: Sirius Meibography. Eye Contact Lens 2020;46 Suppl 2:S135-s140. Lee Y, Hyon JY, Jeon HS. Characteristics of dry eye patients with thick tear film lipid layers evaluated by a LipiView II interferometer. Graefes Arch Clin Exp Ophthalmol 2021;259(5):1235-1241. Eom Y, Lee JS, Kang SY, Kim HM, Song JS. Correlation between quantitative measurements of tear film lipid layer thickness and meibomian gland loss in patients with obstructive meibomian gland dysfunction and normal controls. Am J Ophthalmol 2013;155(6):1104-1110.e2. Finis D, Pischel N, Schrader S, Geerling G. Evaluation of lipid layer thickness measurement of the tear film as a diagnostic tool for Meibomian gland dysfunction. Cornea 2013;32(12):1549-53. Blackie CA, Solomon JD, Scaffidi RC, Greiner JV, Lemp MA, Korb DR. The relationship between dry eye symptoms and lipid layer thickness. Cornea 2009;28(7):789-94. Isreb MA, Greiner JV, Korb DR, et al. Correlation of lipid layer thickness measurements with fluorescein tear film break-up time and Schirmer's test. Eye (London, England) 2003;17(1):79-83. Yang MK, Sa HS, Kim N, et al. Quantitative analysis of morphological and functional alterations of the meibomian glands in eyes with marginal entropion. PloS one 2022;17(4):e0267118. Jie 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):440-446. Wang MTM, Tien L, Han A, et al. Impact of blinking on ocular surface and tear film parameters. Ocul Surf 2018;16(4):424-429. Nakamori K, Odawara M, Nakajima T, Mizutani T, Tsubota K. Blinking is controlled primarily by ocular surface conditions. Am J Ophthalmol 1997;124(1):24-30. Tsubota K. Tear dynamics and dry eye. Prog Retin Eye Res 1998;17(4):565-96. Baek SH, Heo NH, Lee KS. Corneal Topographic Changes after Surgery in Epiblepharon Children. J Korean Ophthalmol Soc. 10 2002;43(10):1841-1846. Kim MS, Lee DS, Woo KI, Chang HR. Changes in astigmatism after surgery for epiblepharon in highly astigmatic children: a controlled study. J AAPOS 2008;12(6):597-601. Preechawai P, Amrith S, Wong I, Sundar G. Refractive changes in epiblepharon. Am J Ophthalmol 2007;143(5):835-839. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 07 Mar, 2025 Read the published version in BMC Ophthalmology → Version 1 posted Editorial decision: Revision requested 31 May, 2024 Submission checks completed at journal 25 May, 2024 Editor assigned by journal 25 May, 2024 First submitted to journal 23 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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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-4469670","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":309040595,"identity":"2a33b603-6229-429f-a237-108efca6dbb4","order_by":0,"name":"Seongmi Kim","email":"","orcid":"","institution":"Jeju National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Seongmi","middleName":"","lastName":"Kim","suffix":""},{"id":309040596,"identity":"b5a83741-ede3-4a23-bcb0-5d76eda7d81b","order_by":1,"name":"Da Eun Yoon","email":"","orcid":"","institution":"Seoul National University Bundang Hospital, Seoul National University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Da","middleName":"Eun","lastName":"Yoon","suffix":""},{"id":309040597,"identity":"af82db51-b7ff-4436-b62a-839c3c2e3e67","order_by":2,"name":"Namju Kim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYDAD9gbmxsdgFjNzA3FaeA4wNhtDtDCCtBgQpaVNGsIkoMW8vf3hY949dnI8Eolt1QU1d6L52xkbmAsq/uDUInPmjLExz7NkY5CW2zOOPcudcRioZcYZ3LZISOSwSfMcOJC4H6SFh+1wbgNIC28bHi3yz5+BtNT3ALUU8/w7nDsfrOUfPlsYzEBaEkAOAxp+OHcDWEsDHi08OcaGcw4kG/bwPGyW5u07nLsRqOUwzzFj3FrYjz988OaAnTwPe/LBzzzfDufOO3/44GOeGjmcWrCDAySqHwWjYBSMglGABgCo9FKZ+BnXcQAAAABJRU5ErkJggg==","orcid":"","institution":"Seoul National University Bundang Hospital, Seoul National University College of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Namju","middleName":"","lastName":"Kim","suffix":""},{"id":309040598,"identity":"e350ae1d-f988-4293-a03c-5c0e1c5d68ea","order_by":3,"name":"Hyun Sun Jeon","email":"","orcid":"","institution":"Seoul National University Bundang Hospital, Seoul National University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Hyun","middleName":"Sun","lastName":"Jeon","suffix":""}],"badges":[],"createdAt":"2024-05-24 03:06:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4469670/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4469670/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12886-025-03940-0","type":"published","date":"2025-03-07T15:56:54+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":58077938,"identity":"3b164c11-e762-4254-87d9-1cd2aa72760f","added_by":"auto","created_at":"2024-06-10 22:53:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":66145,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow diagram illustrating patient selection and allocation for postoperative assessments. \u003c/strong\u003eAmong a total of 109 patients who underwent lower eyelid epiblepharon surgery who were eligible for the study, 21 were excluded based on the following exclusion criteria: two had congenital diseases, one had a concurrent ophthalmic disorder, and 18 had collaboration with strabismus surgery. Finally, 176 eyes of 88 patients who met the inclusion criteria were included. Among them, meibography was available for 72 eyes of 36 patients, topography for 170 eyes of 85 patients and total blink rate and lipid layer thickness for 150 eyes of 75 patients, excluding inadequate data quality for each, respectively.\u003c/p\u003e","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4469670/v1/1de685b649920e3218bb025d.png"},{"id":58077939,"identity":"d8930ce0-f219-42a1-9e15-c962fa2e0c9d","added_by":"auto","created_at":"2024-06-10 22:53:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":114533,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMean changes in subgroups A and B between preoperative and postoperative groups. High Astigmatism is defined as ≥2.0 D, and Low Astigmatism as \u0026lt;2.0 D.\u003c/strong\u003e In the “high astigmatism group,” the corneal astigmatism was significantly decreased after surgery from 3.64 ± 1.77D to 2.41 ± 1.03D (p\u0026lt;0.001). On the other hand, in the “low astigmatism group,” the corneal astigmatism was significantly increased after surgery from 1.10 ± 0.49D to 1.44 ± 1.55D (p=0.02).\u003c/p\u003e\n\u003cp\u003e*Statistically significant differences between the two groups were identified (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05) using a paired t-test.\u003c/p\u003e","description":"","filename":"OnlineFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4469670/v1/13d475eaef106a458894eb99.png"},{"id":78190733,"identity":"ab69460b-23f6-4d44-8b2e-b34844e9156f","added_by":"auto","created_at":"2025-03-10 19:50:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":858042,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4469670/v1/8951d581-df4b-46e7-9cec-87a39fd3c091.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The effects of lower eyelid epiblepharon surgery on the meibomian glands","fulltext":[{"header":"Background","content":"\u003cp\u003eEpiblepharon is a common eyelid condition characterized by horizontal skin folds that may extend over the eyelid margin, causing the eyelashes to touch the corneal surface \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. This condition is frequently observed in both lower eyelids of East Asian children and is traditionally managed through surgical intervention \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. The corrective surgical procedure for lower eyelid epiblepharon involves suturing the subcutaneous tissue of the upper skin edge and the lower margin of the tarsus to achieve outward rotation of the eyelashes \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. However, concerns have been raised regarding the potential impact of this surgical procedure on meibomian glands (MG) located within the tarsus.\u003c/p\u003e \u003cp\u003eThe MG, which is located within the tarsal plate of both the upper and lower eyelids, plays a crucial role in maintaining tear film stability and overall ocular surface health. A previous study by Christoph et al. \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e demonstrated an improvement in MG function after the implementation of a lateral canthal sling procedure in patients with age-related lid laxity. Conversely, Vaidya et al. \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e examined changes in MG function following eyelid corrective surgery in patients with involutional entropion and concluded that there were no significant postoperative alterations in MG function. However, there is a significant gap in our understanding of how morphology or function of MG are affected after surgical correction of the lower eyelid epiblepharon, as no study has specifically addressed this issue. Therefore, the primary objective of this study is to assess and compare morphological and functional changes of MG in pediatric patients who underwent surgery for lower eyelid epiblepharon, using the LipiView\u0026reg;II ocular surface interferometer.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePopulation\u003c/h2\u003e \u003cp\u003e This retrospective study was approved by the Institutional Review Board of the Seoul National University Bundang Hospital (IRB No. B-2401-875-106), and adhered to the tenets of the Declaration of Helsinki. The study included patients aged 19 and under who underwent lower eyelid epiblepharon surgery at Seoul National University Bundang Hospital from May 2022 to April 2023.\u003c/p\u003e \u003cp\u003eSurgical indications for congenital lower eyelid epiblepharon were significant irritation symptoms and corneal erosions matching the extent of the epiblepharon. All patients underwent surgical correction of bilateral lower eyelid epiblepharon. Informed consent for surgical procedures was obtained from the parents of all patients. All surgeries were performed by a single experienced oculoplastic surgeon (NK) using the rotating suture technique.\u003c/p\u003e \u003cp\u003ePatients with a history of congenital diseases, those concurrently afflicted with other ophthalmic conditions, and those undergoing collaborative surgery involving additional ophthalmic procedures were excluded from the study. Additionally, eyes with unreliable measurements due to inadequate data quality in both preoperative and postoperative examinations as well as cases lost to follow-up were excluded from the analyses (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgical Technique\u003c/h2\u003e \u003cp\u003eA subciliary skin incision line was marked horizontally from the temporal point of the inferior punctum along the entire lid length, 1 mm below the ciliary line. Local infiltration of 2% lidocaine mixed with epinephrine at a ratio of 1:100,000 was given subcutaneously along the marked line. Following skin preparation, the upper eyelid was retracted superiorly to avoid obscuring the margin of the lower lid by the cilia of the upper lid. The subciliary skin was incised along the previous mark with a No.15 scalpel blade, while the lid was held using chalazion forceps. The chalazion forceps were removed and dissection was performed inferiorly between the orbicularis muscle and tarsus using monopolar cautery until the lower margin of the tarsus was exposed. The pretarsal orbicularis oculi muscle remaining beneath the upper edge of the skin incision was excised using Westcott scissors until the tarsal plate was more exposed. The subcutaneous tissue at the upper edge of the incised subciliary skin was fixed to the lower margin of the tarsus using five to seven interrupted 8\u0026ndash;0 nylon sutures to ensure outward eversion of the cilia. The lower edge of the incised skin was lifted to overlap the upper skin edge. A line was drawn on the overlapping lower skin to match the upper skin wound edge under it, and the redundant tissue was excised using Stevens' scissors. The skin was closed continuously with 5\u0026ndash;0 rapid vicryl in young patients and with 6\u0026ndash;0 black silk in patients older than 10 years of age. At the conclusion of the procedure, a small amount of antibiotic ointment was applied to the skin wound, and cold compressions were applied for the first 12 hours postoperatively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003ePatient demographic information, including age and sex, was also obtained. Patient data were collected before surgery and at 2 months postoperatively. The outcome measures included meibography, lipid layer thickness (LLT), total blink rate, corneal astigmatism, and refractive astigmatism. Meibography, LLT, and total blink rate were measured using a LipiView\u0026reg;II ocular surface interferometer (TearScience Inc, Morrisville, NC, USA). Corneal astigmatism was measured using an OPD-Scan III (Nidek Technologies, Gamagori, Japan) and refractive astigmatism was measured using a KR-800A (Topcon, Tokyo, Japan).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eGrading of Meibomian Gland Dropout\u003c/h2\u003e \u003cp\u003eAs we included patients who underwent epiblepharon surgery on both lower eyelids, the assessment of the meibograde was concentrated exclusively on the lower lid. The grading system for partial or complete loss of the MG in the lower eyelid included the following four categories: grade 0 (no loss of the MG); grade 1 (area loss comprising less than one-third of the total MG area); grade 2 (area loss ranging from one-third to two-thirds); and grade 3 (area loss exceeding two-thirds) \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eIBM SPSS version 27.0 (IBM Corp., Armonk, NY, USA) was used for the statistical analyses. A paired t-test was performed to compare the preoperative and postoperative values, and quantitative variables were presented as mean and standard deviation (SD). A \u003cem\u003ep\u003c/em\u003e-value of less than 0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 109 patients who underwent epiblepharon surgeries, 21 were excluded based on the following exclusion criteria: two had congenital diseases, one had a concurrent ophthalmic disorder, and 18 had collaboration with strabismus surgery. Finally, 176 eyes of 88 patients (mean age: 8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8 years old, range 3 to 18 years) who met the inclusion criteria were included. Among them, meibography was available for 72 eyes of 36 patients (40.9%), total blink rate and LLT for 150 eyes of 75 patients (85.2%), and topography for 170 eyes of 85 patients (96.6%).\u003c/p\u003e \u003cp\u003eThere was no statistically significant difference between preoperative meibograde (0.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.64) and postoperative meibograde (0.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.42, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\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\u003eChange of clinical parameters after lower eyelid epiblepharon correction surgery\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003cp\u003e(eyes)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eMeibograde\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eLipid layer thickness (nm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e66.30\u0026thinsp;\u0026plusmn;\u0026thinsp;27.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e66.59\u0026thinsp;\u0026plusmn;\u0026thinsp;24.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eTotal blink rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.03\u0026thinsp;\u0026plusmn;\u0026thinsp;5.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.85\u0026thinsp;\u0026plusmn;\u0026thinsp;4.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.02\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eAstigmatism (D)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCorneal Astigmatism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRefractive Astigmatism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.04\u0026thinsp;\u0026plusmn;\u0026thinsp;1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.05\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHigh Astigmatism (D)\u003c/p\u003e \u003cp\u003e(Corneal Astigmatism\u0026thinsp;\u0026ge;\u0026thinsp;2.0D)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCorneal Astigmatism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.41\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRefractive Astigmatism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.75\u0026thinsp;\u0026plusmn;\u0026thinsp;1.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLow Astigmatism (D)\u003c/p\u003e \u003cp\u003e(Corneal Astigmatism\u0026thinsp;\u0026lt;\u0026thinsp;2.0D)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCorneal Astigmatism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.44\u0026thinsp;\u0026plusmn;\u0026thinsp;1.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.02\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRefractive Astigmatism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.68\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.66\u0026thinsp;\u0026plusmn;\u0026thinsp;0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eValues are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003csup\u003e*\u003c/sup\u003eStatistically significant differences between two groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) by paired \u003cem\u003et\u003c/em\u003e-test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe LLT was not significantly different between preoperative (66.30\u0026thinsp;\u0026plusmn;\u0026thinsp;27.36 nm) and postoperative measurements (66.59\u0026thinsp;\u0026plusmn;\u0026thinsp;24.83, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.91). However, the total blink rate was significantly decreased postoperatively (6.85\u0026thinsp;\u0026plusmn;\u0026thinsp;4.91) compared to preoperatively (8.03\u0026thinsp;\u0026plusmn;\u0026thinsp;5.04; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn all eyes, there were no significant changes in corneal or refractive astigmatism after surgery. Mean corneal astigmatism was 1.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.63 diopter (D) and 1.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1.47 D before and after surgery, respectively (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.20). Mean refractive astigmatism was 1.04\u0026thinsp;\u0026plusmn;\u0026thinsp;1.04 D and 1.05\u0026thinsp;\u0026plusmn;\u0026thinsp;1.09 D before and after surgery, respectively (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.75, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). We conducted a subgroup analysis by categorizing eyes into two subgroups based on the level of corneal astigmatism: a \u0026ldquo;high astigmatism group (57 eyes from 57 patients)\u0026rdquo; with corneal astigmatism equal to or exceeding 2.0D and a \u0026ldquo;low astigmatism group (113 eyes from 67 patients)\u0026rdquo; with corneal astigmatism below 2.0D. In the \u0026ldquo;high astigmatism group,\u0026rdquo; the corneal astigmatism was significantly decreased after surgery from 3.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.77D to 2.41\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03D (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). However, in the \u0026ldquo;low astigmatism group,\u0026rdquo; the corneal astigmatism was significantly increased after surgery from 1.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49D to 1.44\u0026thinsp;\u0026plusmn;\u0026thinsp;1.55D (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Regarding refractive astigmatism, there was no statistically significant difference observed in both the \u0026ldquo;high\u0026rdquo; and the \u0026ldquo;low\u0026rdquo; astigmatism groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.39 and \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.63, respectively) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDuring the epiblepharon surgery, there is a postulation that it may influence the structure of the MG. However, there is currently a lack of research in this regard. This is the first study to evaluate the morphological and functional changes in the MG after epiblepharon surgery. Our study confirmed that there were no significant changes in the meibograde or LLT after surgery, indicating that lower eyelid epiblepharon surgery does not have a substantial short-term impact on the structure or function of the MG.\u003c/p\u003e \u003cp\u003eIn a healthy eyelid, the ductules of the MG contain keratohyalin granules, and their openings are located in front of the mucocutaneous junction. This positioning allowed for the direct delivery of meibum into the tear meniscus \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. If epiblepharon surgery causes subtle structural changes in the MG, it could be hypothesized that it may potentially impact the function of the MG. Meibography is a widely used diagnostic imaging technique for meibomian gland dysfunction (MGD). This enables the objective and reproducible observation of MG \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. While it is a short-term observation over a period of 2 months, our study is meaningful as the first report on the changes in MG by evaluating meibography following epiblepharon surgery, a procedure frequently performed in pediatric patients.\u003c/p\u003e \u003cp\u003eLLT is considered an indicator that plays a role in preventing tear evaporation in patients with dry eye, although the standard has not been clearly established \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Additionally, it is regarded as one of the indicators for assessing the function of the MG \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Reduced LLT may be indicative of dry eye, and MGD is associated with their manifestations \u003csup\u003e\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. In a previous study, after the surgical correction of marginal entropion, repositioning of the MG ducts and orifices facilitated the release of pooled secretions, leading to an increase in LLT \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. However, the results of this study indicated that there were no statistically significant changes in LLT after surgery. Considering that neither meibograde nor LLT showed postoperative changes, it can be inferred that, in the short term, surgery does not affect MG function.\u003c/p\u003e \u003cp\u003eThe blink patterns and rate are associated with tear breakup time (TBUT), and Ocular Surface Disease Index (OSDI) in dry eye disease \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Individuals with dry eyes tend to blink more frequently to improve the tear distribution on the ocular surface \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. This increased blinking compensates for the reduced tear production and may be caused by discomfort on the ocular surface \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. In this study, the total blink rate significantly decreased from 8.03\u0026thinsp;\u0026plusmn;\u0026thinsp;5.04 before epiblepharon surgery to 6.85\u0026thinsp;\u0026plusmn;\u0026thinsp;4.91 after surgery (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02). The significant decrease in the blink rate after surgery may be related to the alleviation of discomfort from postoperative eyelash irritation. Additionally, this could be interpreted as a reduction in the compensatory mechanism due to a decrease in tear film instability.\u003c/p\u003e \u003cp\u003eAstigmatism is also associated with epiblepharon. There have been conflicting reports regarding changes in astigmatism after surgery, with some studies suggesting a decrease, while others showing no significant difference \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. In our study, corneal astigmatism significantly decreased by 1.23D only in the high astigmatism group, while it significantly increased by 0.34D in the low astigmatism group. The substantial change in corneal astigmatism observed in the high astigmatism group in our study aligns with the findings of Kim et al. \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e who observed a correlation between higher preoperative astigmatism levels and substantial postoperative changes in astigmatism. These results can also be interpreted as that corneal erosion caused by epiblepharon may impact the accuracy of topography, potentially normalizing evaluations that were previously overestimated or underestimated due to corneal erosion.\u003c/p\u003e \u003cp\u003eThere are several limitations in our study. First, the postoperative observational period was short by 2 months. However, we believe that this is enough to assess the structural impact associated with surgery. Second, owing to the pediatric nature of the patients, there were difficulties in obtaining cooperation during examinations, which could have impacted the quality of meibography, leading to the exclusion of some cases. However, we believe that the impact on the results was minimal, as we excluded cases with difficulty in cooperation or low-quality examinations from the analysis.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study suggests that lower eyelid epiblepharon surgery in pediatric patients does not significantly alter the structure and function of the MG. Additionally, stabilizing the ocular surface through surgical correction may have beneficial effects on blink rate and astigmatism. When making surgical decisions, correction surgery for lower eyelid epiblepharon can be performed without worrying about adverse effects on the MG.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy design: HSJ, NK\u003c/p\u003e\n\u003cp\u003eWriting the article: SK, DEY, HSJ, NK\u003c/p\u003e\n\u003cp\u003eData collection: SK, DEY\u003c/p\u003e\n\u003cp\u003eAnalysis and interpretation of the data: SK, DEY\u003c/p\u003e\n\u003cp\u003eLiterature search: SK, DEY, HSJ, NK\u003c/p\u003e\n\u003cp\u003eCritical revision of the article: SK, DEY, HSJ, NK\u003c/p\u003e\n\u003cp\u003eFinal approval of the article: HSJ, NK\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate.\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of the Seoul National University Bundang Hospital (IRB No. B-2401-875-106), and adhered to the tenets of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLevitt JM. Epiblepharon and congenital entropion. Am J of Ophthalmol 1957;44(1):112-3. \u003c/li\u003e\n\u003cli\u003eShih MH, Huang FC. Astigmatism in children with epiblepharon. Cornea 2007;26(9):1090-4. \u003c/li\u003e\n\u003cli\u003eSundar G, Young SM, Tara S, Tan AM, Amrith S. Epiblepharon in East asian patients: the singapore experience. Ophthalmology 2010;117(1):184-9. \u003c/li\u003e\n\u003cli\u003eYang MK, Kim N, Choung HK, Khwarg SI. Effect of Congenital Lower Eyelid Epiblepharon Surgery on Asymmetric Margin Reflex Distance 1. Curr Eye Res 2021;46(7):954-960. \u003c/li\u003e\n\u003cli\u003eHoltmann C, Finis D, Knop E, Borrelli M, Geerling G. Lateral Canthal Sling Procedure for Meibomian Gland Dysfunction? Results of a Pilot Study. Curr Eye Res 2021;46(10):1489-1494. \u003c/li\u003e\n\u003cli\u003eVaidya A, Kakizaki H, Takahashi Y. Postoperative changes in status of meibomian gland dysfunction in patients with involutional entropion. Int Ophthalmol 2020;40(6):1397-1402.\u003c/li\u003e\n\u003cli\u003eArita R, Itoh K, Inoue K, Amano S. Noncontact infrared meibography to document age-related changes of the meibomian glands in a normal population. Ophthalmology 2008;115(5):911-5. \u003c/li\u003e\n\u003cli\u003eKnop E, Knop N, Zhivov A, et al. The lid wiper and muco-cutaneous junction anatomy of the human eyelid margins: an in vivo confocal and histological study. J Anat 2011;218(4):449-61. \u003c/li\u003e\n\u003cli\u003eArita R. Meibography: A Japanese Perspective. Invest Ophthalmol Vis Sci 2018;59(14):Des48-des55. \u003c/li\u003e\n\u003cli\u003eGulmez Sevim D, Gumus K, Unlu M. Reliable, Noncontact Imaging Tool for the Evaluation of Meibomian Gland Function: Sirius Meibography. Eye Contact Lens 2020;46 Suppl 2:S135-s140. \u003c/li\u003e\n\u003cli\u003eLee Y, Hyon JY, Jeon HS. Characteristics of dry eye patients with thick tear film lipid layers evaluated by a LipiView II interferometer. Graefes Arch Clin Exp Ophthalmol 2021;259(5):1235-1241. \u003c/li\u003e\n\u003cli\u003eEom Y, Lee JS, Kang SY, Kim HM, Song JS. Correlation between quantitative measurements of tear film lipid layer thickness and meibomian gland loss in patients with obstructive meibomian gland dysfunction and normal controls. Am J Ophthalmol 2013;155(6):1104-1110.e2. \u003c/li\u003e\n\u003cli\u003eFinis D, Pischel N, Schrader S, Geerling G. Evaluation of lipid layer thickness measurement of the tear film as a diagnostic tool for Meibomian gland dysfunction. Cornea 2013;32(12):1549-53. \u003c/li\u003e\n\u003cli\u003eBlackie CA, Solomon JD, Scaffidi RC, Greiner JV, Lemp MA, Korb DR. The relationship between dry eye symptoms and lipid layer thickness. Cornea 2009;28(7):789-94. \u003c/li\u003e\n\u003cli\u003eIsreb MA, Greiner JV, Korb DR, et al. Correlation of lipid layer thickness measurements with fluorescein tear film break-up time and Schirmer\u0026apos;s test. Eye (London, England) 2003;17(1):79-83. \u003c/li\u003e\n\u003cli\u003eYang MK, Sa HS, Kim N, et al. Quantitative analysis of morphological and functional alterations of the meibomian glands in eyes with marginal entropion. PloS one 2022;17(4):e0267118. \u003c/li\u003e\n\u003cli\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):440-446. \u003c/li\u003e\n\u003cli\u003eWang MTM, Tien L, Han A, et al. Impact of blinking on ocular surface and tear film parameters. Ocul Surf 2018;16(4):424-429. \u003c/li\u003e\n\u003cli\u003eNakamori K, Odawara M, Nakajima T, Mizutani T, Tsubota K. Blinking is controlled primarily by ocular surface conditions. Am J Ophthalmol 1997;124(1):24-30. \u003c/li\u003e\n\u003cli\u003eTsubota K. Tear dynamics and dry eye. Prog Retin Eye Res 1998;17(4):565-96. \u003c/li\u003e\n\u003cli\u003eBaek SH, Heo NH, Lee KS. Corneal Topographic Changes after Surgery in Epiblepharon Children. J Korean Ophthalmol Soc. 10 2002;43(10):1841-1846. \u003c/li\u003e\n\u003cli\u003eKim MS, Lee DS, Woo KI, Chang HR. Changes in astigmatism after surgery for epiblepharon in highly astigmatic children: a controlled study. J AAPOS 2008;12(6):597-601. \u003c/li\u003e\n\u003cli\u003ePreechawai P, Amrith S, Wong I, Sundar G. Refractive changes in epiblepharon. Am J Ophthalmol 2007;143(5):835-839.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Meibomian gland, Epiblepharon, Meibography, Astigmatism","lastPublishedDoi":"10.21203/rs.3.rs-4469670/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4469670/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTo investigate the morphological and functional changes of meibomian glands (MG) in pediatric patients who underwent surgery for lower eyelid epiblepharon.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 176 eyes of 88 patients aged 19 and under (mean age: 8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8 years old) who underwent bilateral lower eyelid epiblepharon correction surgery from May 2022 to April 2023 were included. Meibograde, lipid layer thickness (LLT), total blink rate, and corneal/refractive astigmatism were compared between pre- and 2 months postoperatively.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThere were no statistically significant changes in meibograde and LLT after surgery. The total blink rate was significantly decreased after surgery (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02). While corneal and refractive astigmatism showed no significant changes in total eyes, corneal astigmatism in eyes of high astigmatism of 2.0D or more subgroup exhibited a significant decrease postoperatively (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eLower eyelid epiblepharon surgery in pediatric patients does not significantly alter the structure and function of the MG. Additionally, stabilizing the ocular surface through surgical correction may have beneficial effects on blink rate and corneal astigmatism. Although the long-term evaluation would be needed, we suggest that lower eyelid epiblepharon surgery could be performed without worrying about adverse effects on the MG.\u003c/p\u003e","manuscriptTitle":"The effects of lower eyelid epiblepharon surgery on the meibomian glands","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-10 22:53:46","doi":"10.21203/rs.3.rs-4469670/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-31T10:37:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-25T06:50:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-25T06:50:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Ophthalmology","date":"2024-05-24T03:05:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"aa5fcca2-5432-4b75-95e1-3c707673e54b","owner":[],"postedDate":"June 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-10T19:47:40+00:00","versionOfRecord":{"articleIdentity":"rs-4469670","link":"https://doi.org/10.1186/s12886-025-03940-0","journal":{"identity":"bmc-ophthalmology","isVorOnly":false,"title":"BMC Ophthalmology"},"publishedOn":"2025-03-07 15:56:54","publishedOnDateReadable":"March 7th, 2025"},"versionCreatedAt":"2024-06-10 22:53:46","video":"","vorDoi":"10.1186/s12886-025-03940-0","vorDoiUrl":"https://doi.org/10.1186/s12886-025-03940-0","workflowStages":[]},"version":"v1","identity":"rs-4469670","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4469670","identity":"rs-4469670","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}