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Estimated Marginal Means of Upper and Lower Fornix Depths and Intercanthal Distances per Age Group and Separated by Sex
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Purpose:
Quantifying the extent of conjunctival fibrosis for documentation of progression in conjunctival scarring disease is a clinical challenge. Measurement of forniceal foreshortening facilitates monitoring of these disorders. This study aims (1) to define the limits of the normal human conjunctival fornices and how these alter with age and (2...
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Objectives:
This study aimed to investigate the trajectory of change of diverse attention and working memory in Koreans from 4 to 40 years of age.
Methods:
The data of 912 subjects from 4 to 15 years of age obtained from a previous standardization study of the computerized comprehensive attention test were merged with the newly obtained data of...
To examine the changes in meibomian glands associated with aging in a normal Korean population and to estimate the differences between the upper and lower eyelid in each age group.
Citations
... Skull variations among ethnic subgroups in the cranial anthropological hierarchy have a potential impact on FD, so establishing normative data on FD for different ethnic groups will also help define this potential effect. 11 In the study, we provide a reference dataset classified by age and sex for comparison with normal FD in the follow-up and treatment of diseases with progressive fornix cicatrization by measuring the lower and upper conjunctival FD in healthy Turkish volunteers. ...
... In addition to providing age-sex specific FD standards in healthy subjects, the management of common clinical diseases such as thyroid orbitopathy, ptosis, and giant fornix syndrome can also be facilitated. 11,21 Early diagnosis of cicatrizing diseases that cause serious morbidity in advanced stages may be possible. It may even be possible to evaluate the success of treatment after such as ocular surface reconstruction surgery and to select the best surgical procedure for each patient by comparing different treatment results. ...
Purpose:
To provide an age and sex-classified reference dataset for normal fornix depth by measuring the lower and upper conjunctival fornix depth (FD) in healthy volunteers.
Methods:
An epidemiological, prospective, cross-sectional study evaluates conjunctival FDs in 301 healthy Turkish volunteers aged 20-83. Fornix measurements were made using a validated fornix depth measurer (FDM).
Results:
The mean age was 49.2 ± 19 in males and 48.6 ± 16.2 in females. The mean upper and lower conjunctival FDs were 15.9 (12-21) mm and 10.1 (6-13) mm, respectively. The mean upper and lower FDs were 15.4 (13-20) mm and 9.7 (6-13) mm in females, and 16.3 (12-21) mm and 10.5 (8-13) mm in males, respectively. .
Conclusion:
When the normative dataset created in healthy Turkish volunteers, it was observed that both the upper and lower FDs were shallower in females and that they gradually became shallower with age. Accordingly, when an evaluation for conjunctival pathology is to be made, the expected normal FD value for both age and sex should be considered.
... Recognizing the limitations of these early methods, various groups have subsequently introduced custom-made devices to facilitate the objective measurements of conjunctival fornices (18,21,22,28,29). Such devices include fornix depth measurers (FDMs), which allow the quantitative measurements of the lower, and in some devices, the upper fornix depths (Figure 1). ...
... This is the first study demonstrating the reproducibility of both upper and lower fornix depth measurements. Subsequent validation studies using a similar FDM was established in healthy eyes of Caucasian and South Asian subjects (28,29). ...
... Unlike published inflammation scoring schemes which have mostly used subjective assessments of conjunctival injection (20,34), the method we introduced was guided by comparison to a standard panel of photographs and showed good inter-observer agreement (interclass correlation coefficient, ICC = 0.88, 95% CI 0.84 -0.90). Good inter-and intra-observer agreements to quantify fornix foreshortening were also achieved with the use of a FDM, similar to that validated in previous studies (22,28,29). Furthermore, this is the first scoring tool that apportioned different weightage to certain OSD manifestations within the scoring system. ...
Cicatricial conjunctival diseases (CCDs), are a diverse group of ocular surface diseases characterized by chronic scarring of the conjunctiva. These diseases can cause significant ocular morbidity. They are life-long once acquired and can be debilitating, painful diseases leading to visual loss. A recent international consensus of ocular surface disease experts have placed emphasis on the need of validated clinical disease scoring systems for CCDs, important for the objective evaluation of disease severity, outcomes of therapies, and longitudinal monitoring of disease. This review aims to describe the various published clinical disease scoring systems available for CCDs and evaluates the benefits and limitations of each system. It can be used as a guide for clinicians managing patients with CCDs and for researchers evaluating potential therapies in clinical trials.
... Only two of these 11 systems, measuring conjunctival scarring using different quantitative methods, have had both inter-and intra-observer variability evaluated and have been compared with another methodology. One has not been used in any studies [13] whereas the other [12], a fornix depth measurer (FDM), has been used to evaluate the normal upper and lower fornix depths in both healthy South-Asian [22] and Caucasian populations [23]. The latter has also been used to assess the progression of conjunctival scarring in ocular MMP [24]. ...
... The upper and lower central fornix depths were measured using our custom-made FDM validated in a previous study [12] and previously used to establish normal values for the upper and lower fornices in healthy Caucasians [23] and South-East Asians [22] (Supplementary Fig. 1; supplementary video). The guidance for the use of the FDM is found in our finalized concise clinical assessment tool for CC (Supplementary Appendix 2). ...
... Studies have indicated that subjective measures to evaluate scarring are not as good as objective measures [12]. Recognising the limitations of these methods, various groups have since introduced devices to facilitate the objective evaluation of the conjunctival fornices [11,12,19,22,23]. Such devices include the FDM, which allow quantitative measurements of the lower, and in some devices, the upper forniceal depths. ...
Purpose:
This study was designed to validate a semi-quantitative clinical assessment tool for cicatrising conjunctivitis (CC).
Methods:
Fifty-five patients (109 eyes) with mucous membrane pemphigoid (MMP) and 31 patients (61 eyes) with Stevens-Johnson syndrome (SJS) were included. Three methods were used for validation: (1) comparison of inter-and intra-observer reproducibility for the components selected for the initial version of the tool, (2) quantitative measurement of the scarring component with a fornix depth measurer, compared with qualitative Tauber grading methodology, (3) the final version of the tool was compared with the published Sotozono SJS grading system. Main outcome measures included: inter- and intra-observer reproducibility, calculation of composite measures of scarring and morbidity, component redundancy, and correlation with other grading systems.
Results:
Inter- and intra-observer agreement was moderate-to-excellent for graded components of conjunctival hyperaemia, upper and lower symblepharon, upper and lower fornix depth, corneal vascularisation, and corneal opacity. There was poor-to-good agreement for limitation of motility which was rejected from inclusion in the final tool. Composite scores for scarring components and morbidity components showed good-to-excellent agreement and distribution of ocular disease severity. Analysis of the composite components showed no redundancy - all components contributed independently. Comparison with both Tauber and Sotozono grading methodologies showed good concordance.
Conclusions:
This study has developed the first validated assessment tool applicable to causes of CC. The tool is concise and discriminates patients with varying disease severity. It measures both disease activity and severity and is suitable for clinical and research applications.
... Forniceal foreshortening has been described as a quantifiable means of objectively measuring the extent of the fibrosis [71]. The normal depth of the conjunctival fornix has been documented for healthy South Asian [72] and Caucasian [73] populations. Fornix depth measurers have been used and validated for the measurement of fornix depth, providing reproducible results and facilitating the monitoring of conjunctival scarring [74]. ...
Mucous membrane pemphigoid (MMP) is a systemic cicatrizing autoimmune disease that primarily affects orificial mucous membranes, such as the conjunctiva, the nasal cavity, the oropharynx, and the genitalia. Ocular involvement occurs in about 70% of all MMP cases. Ocular MMP (OcMMP) also encompasses the conditions linear immunoglobulin A disease, mucosal dominated epidermolysis bullosa acquisita, and anti-laminin 332/anti-epiligrin/anti-laminin 5 pemphigoid. It is a complex clinical entity that may lead to ocular surface failure and result in inflammatory and infectious complications, as well as potentially devastating visual loss. Early diagnosis and appropriate treatment are of paramount importance and require a high level of expertise as this condition can be extremely challenging to diagnose and treat even for experienced clinicians. In this review we provide an up-to-date insight on the pathophysiology of OcMMP, with an emphasis on the current state of its diagnostics and therapeutics. Our the aim is to increase our understanding of OcMMP and highlight modern diagnostic and therapeutic options.
... Based on the result analysis, these parameters can be applied generally in ocular defect patients with different genders and various ages of adulthood. Although publications showed that normal ocular dimensions in adults varied with age and gender among different biometric parameters, 13,34 vertical and horizontal diameters were not found much different between males and females at any ages. 28 There was also no clear evidence to explain variation in ocular dimensions with gender, but that might be due to differences in genetic and environmental factors. ...
Objective: This study aimed to evaluate three factors affecting dimensions of the '3D ocular prosthesis' in patients rehabilitated at Mahidol University. Materials and Methods: A cross-sectional study was conducted on non-irradiated and healthy anophthalmic patients, including 82 subjects aged above 15 years old. All 82 customized ocular prostheses, fabricated following the Mahidol University's patent, were measured with a digital caliper (Mitutoyo 573 Digimatic Absolute Point Caliper) in horizontal, vertical, and anteroposterior (thickness) dimensions. Three main factors (age, gender, and surgical techniques) were evaluated in relations to the dimensions of an ocular prosthesis. The data were statistically analyzed using an independent t-test and a one-way ANOVA. Results: An independent t-test showed that a horizontal dimension was significantly greater in males than females (p=0.020), and a thickness dimension was significant difference in surgical techniques, which enucleation technique showed thicker ocular prosthesis compared with evisceration technique (p=0.024). However, one-way ANOVA showed that all dimensions of an ocular prosthesis were not significant differences among age groups (p>0.05). Conclusion: This study presented the first set of data for the 3D ocular prosthesis in patients rehabilitated at Mahidol University. Gender had an effect on horizontal dimension whilst surgical technique had an effect on the thickness of ocular prosthesis.
... 3. In Ophthalmology, ELSEVIER has published with some modification in pervious study in Feb. 2014 "Defining the limits of normal conjunctival fornix anatomy in a healthy South Asian population 3 ." 4. A study has also published in Oct. 2016 by the Scientific Journal of the Royal College of Ophthalmologists "Upper and lower conjunctival fornix depth in healthy white caucasian eyes: a method of objective assessment 4 ." ...
The precise measurement of fornix depth in ophthalmic science is a challenging task for the correct diagnosis of Symblepharon. In the present
scenario, the precise method of fornix depth measurement is not available in the public domain. There are some methods, which have been
emerge as beneficial but in the routine work, it was observed that these methods are not accurate as per the require procedure to diagnose the
severity of the disease. It is essential to evaluate the anti-scarring treatment require objective evaluation of the scarring with understanding of
standard fornix structure. In all existing methods probability of error is very high.
Symblepharon is a type of conjunctival problems, which occurs when adhesions arises between bulbar and palpebral conjunctiva1. This can
happen in a number of situations like a burns injury with recurrent pterygia, in Stevens-Johnson syndrome etc2.
The quantifying amount of conjunctival fibrosis used for records of development within conjunctival scarring illness is a medical confront. The
purpose, this opinion was to highlight the existing methods with some critical points to resolve the current problem. It will define the boundaries
of normal conjunctival fornix anatomy, which may be helpful to normative information of superior and inferior fornix depths (FDs) to assess
variability in deferent gauging of fornix depth, area as well as fornix intercanthal space (FICS) in a healthy population. It will be also a need for
the information about the effect of age and sex. In view of the current methods, the problem should be address in the depth. Therefore, we require
a method, which should be beneficial in future for evaluating the cruelty of symblepharon in addition to determination of the post-surgical
prognosis. Conjunctival foreshortening is considerable to ascertaining phase of the progression cicatrizing conjunctivitis (PCC) disease.
... Based on the result analysis, these parameters can be applied generally in ocular defect patients with different genders and various ages of adulthood. Although publications showed that normal ocular dimensions in adults varied with age and gender among different biometric parameters, 13,34 vertical and horizontal diameters were not found much different between males and females at any ages. 28 There was also no clear evidence to explain variation in ocular dimensions with gender, but that might be due to differences in genetic and environmental factors. ...
Objective: This study aimed to evaluate three factors affecting dimensions of the '3D ocular prosthesis' in patients rehabilitated at Mahidol University. Materials and Methods: A cross-sectional study was conducted on non-irradiated and healthy anophthalmic patients, including 82 subjects aged above 15 years old. All 82 standardized ocular prostheses, fabricated following the Mahidol University's patent, were measured with a digital caliper (Mitutoyo 573 Digimatic Absolute Point Caliper) in horizontal, vertical, and anteroposterior (thickness) dimensions. Three main factors (age, gender, and surgical techniques) were evaluated in relations to the ocular prosthesis. The data were statistically analyzed using multifactorial ANOVA (p<0.05). Results: The multifactorial ANOVA showed no significant differences in vertical and horizontal dimensions among all those three factors (p>0.05). However, regarding thickness consideration, statistically significant difference was found in accordance to the surgical technique factor (p=0.012). Conclusion: This study presents the first set of data for the 3D ocular prosthesis in patients rehabilitated at Mahidol University. The factors of age and gender might not affect in all three dimensions of the ocular prosthesis, however the surgical technique could influent thickness of the ocular prosthesis.
... respectively. 9,19 In the anophthalmic sockets, we observed the superior fornix was a median of 6.5 mm preoperatively and 10 mm postoperatively. In our study, the median inferior fornix was 7 mm preoperatively and 8 mm postoperatively. ...
... These outcomes indicate that the contraction in the upper fornix was more important compared to the lower fornix. We observed a significant improvement of fornix depeening with the procedure, but both fornices remained smaller than the fornix from normal eyes 9,19 likely because of the several alterations in the anophthalmic sockets. The remaining lack of fornix depth even after the SMTSG may explain the presence of lagophthalmos and entropion in some patients postoperatively. ...
Purpose:
The aim of thhis study was to present the outcomes of postauricular split-medium thickness skin graft (SMTSG) to treat anophthalmic sockets with contracted fornices.
Methods:
This case series enrolled patients with grade 2 or 3 anophthalmic sockets between 2015 and 2016. Data were collected on patient demographics, objective and subjective parameters preoperatively and 180 days postoperatively. Success of the surgery was graded on the height of the graft, the depth of the superior and inferior fornices, and presence/abscence of lagophthalmos, entropion, and ability to retain an external prosthesis.
Results:
Eighteen patients were enrolled with a mean age of 35.9 ± 18 years. The median height of the graft was 22 mm (25% quartile = 18.75) when removed and 20 mm (25% quartile = 16) postoperatively. The median depth of the superior fornix was 6.5 mm (25% quartile = 4.5 mm) preoperatively and 10 mm (25% quartile = 8 mm) postoperatively (P = 0.5). The median inferior fornix depth was 7 mm (25% quartile = 3.5 mm) preoperatively and 8 mm (25% quartile = 5 mm) (P = 0.27) postoperatively. Preoperatively, there were 13 (72.2%) patients with lagophthalmos, 10 (44.4%) with entropion, 3 (37.5%) with poor prosthesis retention, and 5 (62.5%) who were unable to retain the prosthesis. Postoperatively, 7 (38.9%) patients had lagophthamos, 1 (5.6%) had entropion, and all the patients could retain the prosthesis. None of the sockets had a foul odor postoperatively.
Conclusions:
Postauricular SMTSG achieves successful outcomes for the treatment of contracted anophthalmic sockets, reshaping the anterior socket surface and deepening the fornices.
... This has allowed measurement of the upper fornix, which had previously been omitted due to difficulty of access. Validation studies establishing normal upper and lower fornix baseline values were completed on South Asian and Caucasian populations [97,98]. Even so, these scoring systems were limited because they attempted to measure the conjunctival surface area that existed in a curved three-dimensional structure. ...
Background: Epidermolysis bullosa (EB) and autoimmune blistering diseases (AIBD) describe a group of rare chronic dermatoses characterized by cutaneous fragility and blistering. Although uncommon, significant ocular surface disease (OSD) may occur in both and require ophthalmological assessment. Disease scoring systems have a critical role in providing objective and accurate assessment of disease severity. The objectives of this report were, firstly, to document the prevalence and severity of ocular involvement in EB/AIBD. Secondly, to review and evaluate existing ocular and systemic scoring systems for EB/AIBD. Finally, to identify areas where further development of ocular specific tools in EB/AIBD could be pursued.
Methods: A literature search was performed in October 2017 utilising Medline, Embase, and Scopus databases. The results were restricted by date of publication, between 01.01.1950 and 31.10.2017. The reference lists of these articles were then reviewed for additional relevant publications. Articles of all languages were included if an English translation was available. Articles were excluded if they were duplicates, had no reference to ocular involvement in EB/AIBD or described ocular involvement in other diseases.
Results: Descriptions of ocular involvement in EB/AIBD were identified in 88 peer-reviewed journal articles. Findings reported include but are not limited to: cicatrising conjunctivitis, meibomian gland dysfunction, dry eye disease, trichiasis, symblepharon, fornix fibrosis, keratopathy, ectropion/entropion, ankyloblepharon, corneal ulceration, visual impairment and blindness. Although scoring systems exist for assessment of OSD in mucous membrane pemphigoid, no such tools exist for the other AIBD subtypes or for EB. Several systemic scoring systems exist in the dermatological literature that are efficacious in grading overall EB/AIBD severity, but have limited inclusion of ocular features. To the best of our knowledge, there is no recognised or validated scoring systems which comprehensively stages or grades the spectrum of ocular manifestations in EB/AIBD.
Conclusions: There are a range of ocular complications documented in EB and AIBD. Development of a comprehensive ocular scoring system for EB/AIBD which incorporates the delineation between 'activity' and 'damage' would facilitate more objective patient assessment, improved longitudinal monitoring, comparison of intervention outcomes, and provide commonality for discussion of these patients due to the multidisciplinary nature of their care.
... Clinical data collection and patient sampling were undertaken following ethical approval in accordance with the Declaration of Helsinki (Birmingham East, North and Solihull Ethics Committee: Inflammation in Ocular Surface Disease IOSD 08/ H1206/165, UKCRN 7448). 17 Diagnosis of OcMMP was based on clinical findings characteristic for the disease, namely, progressive conjunctival cicatrization in the absence of other causes of conjunctival scarring. [18][19][20][21][22] If patients did not have a previous positive tissue biopsy, a confirmatory perilesional conjunctival and/or oral mucosal biopsy for direct immunofluorescence was undertaken. ...
Purpose
Ocular mucous membrane pemphigoid (OcMMP) is a rare autoimmune disorder resulting in progressive conjunctival fibrosis and ocular surface failure leading to sight loss in up to 50%. This study was designed to optimize an ocular surface sampling technique for identification of novel biomarkers associated with disease activity and/or progressive fibrosis.
Methods
Fifty-seven patients with OcMMP underwent detailed examination of conjunctival inflammation and fibrosis using fornix depth measurement. Ocular surface impression cytology (OSIC) to sample superior bulbar conjunctiva combined with flow cytometry (OSIC-flow) profiled infiltrating leukocytes. Profiles were compared with healthy controls (HC) and disease controls (primary Sjögren's syndrome, pSS). Thirty-five OcMMP patients were followed every 3 months for 12 months.
Results
Overall neutrophils were elevated in OcMMP eyes when compared to pSS or HC (109 [18%] neutrophils/impression [NPI]; 2 [0.2%]; 6 [0.8%], respectively [P < 0.0001]) and in OcMMP patients with no visible inflammation when compared with HC (44.3 [7.9%]; 5.8 [0.8%]; P < 0.05). At 12 months follow-up, 53% of OcMMP eyes progressed, and this was associated with baseline conjunctival neutrophilia (P = 0.004). As a potential biomarker, a value of 44 NPI had sensitivity, specificity, and positive predictive values of 75%, 70%, and 73%, respectively. Notably, eyes with no visible inflammation and raised conjunctival neutrophils were more likely to progress and have a greater degree of conjunctival shrinkage compared to those without raised neutrophils.
Conclusions
These data suggest that OSIC-flow cytometric analyses may facilitate repeated patient sampling. Neutrophils may act as a biomarker for monitoring disease activity, progressive fibrosis, and response to therapy in OcMMP even when the eye appears clinically uninflamed.
