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Ultrasound imaging in floppy eyelid syndrome: anatomical and clinical considerations Cover

Ultrasound imaging in floppy eyelid syndrome: anatomical and clinical considerations

Journal of Ultrasonography
Volume 25 (2025): Issue 101 (April 2025)
By: Vasilios Batis,  Efstathios Detorakis,  Sophia Schiza,  Emmanuel Prokopakis,  Konstantinos Krasagakis and  Elena Drakonaki  
Open Access
|Jun 2025

Figures & Tables

Fig. 1.

Segmentation of upper eyelid anatomical layers in high-frequency ultrasound imaging of the skin (HFUS). HFUS image of the upper eyelid using a high-frequency (8–18 MHz) linear array hockey stick transducer and the standard “MSK superficial” setting of the manufacturer, showing the anatomical layers of the eyelid soft tissue. The thickness of each layer is measured using the system’s built-in software tool (calipers) as follows: Measurement 1: Thickness of the most superficial epidermis-dermis layer thickness (EDT), extending from the skin surface to the subcutaneous layer, including the subepidermal low echogenicity band (SLEB). Measurement 2: Thickness of the hyperechoic subcutaneous layer, extending from the deep SLEB to the surface of the underlying muscle (SFT). Measurement 3: Thickness of the palpebral part of the orbicularis oculi muscle, demonstrated as hypoechoic linear muscle fibers (OOT). Measurement 4: Thickness of the SLEB, presenting as a thin band of lower echogenicity at the deepest part of the epidermis-dermis layer
Segmentation of upper eyelid anatomical layers in high-frequency ultrasound imaging of the skin (HFUS). HFUS image of the upper eyelid using a high-frequency (8–18 MHz) linear array hockey stick transducer and the standard “MSK superficial” setting of the manufacturer, showing the anatomical layers of the eyelid soft tissue. The thickness of each layer is measured using the system’s built-in software tool (calipers) as follows: Measurement 1: Thickness of the most superficial epidermis-dermis layer thickness (EDT), extending from the skin surface to the subcutaneous layer, including the subepidermal low echogenicity band (SLEB). Measurement 2: Thickness of the hyperechoic subcutaneous layer, extending from the deep SLEB to the surface of the underlying muscle (SFT). Measurement 3: Thickness of the palpebral part of the orbicularis oculi muscle, demonstrated as hypoechoic linear muscle fibers (OOT). Measurement 4: Thickness of the SLEB, presenting as a thin band of lower echogenicity at the deepest part of the epidermis-dermis layer

Fig. 2.

Strain elastography (SE) of the upper eyelid. A, B. Epidermis and dermis layer. B-mode image (A) and corresponding elastography image (B), with color code showing the elasticity scale. The elasticity ratio of the upper eyelid epidermis and dermis layer relative to the subcutaneous fat (skin-to-subcutaneous fat ratio, SFR, A/B) is measured using manually applied ROIs located in the skin (1) and in the fat (2). The respective elasticity values and ratio are automatically calculated and displayed on the screen. C, D. Orbicularis oculi muscle layer. B-mode image (C) and corresponding elastography image (D), with color code showing the elasticity scale. The elasticity ratio of the orbicularis oculi muscle layer to subcutaneous fat (orbicularis-to-fat ratio, OFR, A/B) is measured using manually applied ROIs located in the muscle (1) and in the fat (2). The respective elasticity values and ratio are automatically calculated and displayed on the screen
Strain elastography (SE) of the upper eyelid. A, B. Epidermis and dermis layer. B-mode image (A) and corresponding elastography image (B), with color code showing the elasticity scale. The elasticity ratio of the upper eyelid epidermis and dermis layer relative to the subcutaneous fat (skin-to-subcutaneous fat ratio, SFR, A/B) is measured using manually applied ROIs located in the skin (1) and in the fat (2). The respective elasticity values and ratio are automatically calculated and displayed on the screen. C, D. Orbicularis oculi muscle layer. B-mode image (C) and corresponding elastography image (D), with color code showing the elasticity scale. The elasticity ratio of the orbicularis oculi muscle layer to subcutaneous fat (orbicularis-to-fat ratio, OFR, A/B) is measured using manually applied ROIs located in the muscle (1) and in the fat (2). The respective elasticity values and ratio are automatically calculated and displayed on the screen

Fig. 3.

Shear wave elastography (SWE) of the upper eyelid. A, B. Superficial epidermis-dermis layer. B-mode image (A) and superimposed SWE color coded image showing the elasticity scale (B). Three SWE measurements are performed using circular ROIs manually placed on the imaged area. The quantitative assessment of elasticity in kPa (mean value, maximum, minimum, standard deviation) is presented in a superimposed table. C, D. Subcutaneous fat layer. B-mode image (C) and superimposed SWE color-coded image showing the elasticity scale (D). Three SWE measurements are performed using circular ROIs manually placed on the subcutaneous fat layer. The quantitative assessment of elasticity in kPa (mean value, maximum, minimum, standard deviation) is presented in a superimposed table. E, F. Orbicularis oculi muscle layer. B-mode image (E) and superimposed SWE color-coded image showing the elasticity scale (F). Three SWE measurements are performed using circular ROIs manually placed on the orbicularis oculi muscle. The quantitative assessment of elasticity in kPa (mean value, maximum, minimum, standard deviation) is presented in a superimposed table. In all cases, only the mean value was used for statistical analysis
Shear wave elastography (SWE) of the upper eyelid. A, B. Superficial epidermis-dermis layer. B-mode image (A) and superimposed SWE color coded image showing the elasticity scale (B). Three SWE measurements are performed using circular ROIs manually placed on the imaged area. The quantitative assessment of elasticity in kPa (mean value, maximum, minimum, standard deviation) is presented in a superimposed table. C, D. Subcutaneous fat layer. B-mode image (C) and superimposed SWE color-coded image showing the elasticity scale (D). Three SWE measurements are performed using circular ROIs manually placed on the subcutaneous fat layer. The quantitative assessment of elasticity in kPa (mean value, maximum, minimum, standard deviation) is presented in a superimposed table. E, F. Orbicularis oculi muscle layer. B-mode image (E) and superimposed SWE color-coded image showing the elasticity scale (F). Three SWE measurements are performed using circular ROIs manually placed on the orbicularis oculi muscle. The quantitative assessment of elasticity in kPa (mean value, maximum, minimum, standard deviation) is presented in a superimposed table. In all cases, only the mean value was used for statistical analysis

Fig. 4.

A. Tongue thickness (TT) measurement as the anteroposterior diameter between the echogenic mucosa (arrow) and the surface of the mylohyoid muscle (ML) at the floor of the mouth (dotted line). B. Corresponding placement of the ultrasound probe over the neck area. GH – geniohyoid; TM – intrinsic and extrinsic (genioglossus) muscles of the tongue, ML – mylohyoid muscle; F – subcutaneous fat. C. Upper airway length (UAL) measurement as the anteroposterior diameter between the anterior edge of the hyoid bone (H) and the hyperechoic line corresponding to the air column at the edge of the hard palate (arrows) (D) respective placement of the ultrasound probe over the neck area. GH – geniohyoid; TM – intrinsic and extrinsic (genioglossus) muscles of the tongue; ML – mylohyoid muscle; F – subcutaneous fat; H – hyoid bone shadow; M – mandible shadow
A. Tongue thickness (TT) measurement as the anteroposterior diameter between the echogenic mucosa (arrow) and the surface of the mylohyoid muscle (ML) at the floor of the mouth (dotted line). B. Corresponding placement of the ultrasound probe over the neck area. GH – geniohyoid; TM – intrinsic and extrinsic (genioglossus) muscles of the tongue, ML – mylohyoid muscle; F – subcutaneous fat. C. Upper airway length (UAL) measurement as the anteroposterior diameter between the anterior edge of the hyoid bone (H) and the hyperechoic line corresponding to the air column at the edge of the hard palate (arrows) (D) respective placement of the ultrasound probe over the neck area. GH – geniohyoid; TM – intrinsic and extrinsic (genioglossus) muscles of the tongue; ML – mylohyoid muscle; F – subcutaneous fat; H – hyoid bone shadow; M – mandible shadow

Descriptive statistics for clinical and demographic parameters (mean ± SD, range) for FES and control groups, with independent samples t-test scores and associated levels of statistical significance

ParameterFES mean ± SD (range)Controls mean ± SD (range)Independent samples t-testp
Age (years)65.64 ± 12.9 (40–88)59.21 ± 14.21 (20–78)0.410.15
Weight (kg)93.50 ± 25.0 (64–140)91.00 ± 23.13 (52–135)0.380.69
Height (cm)1.69 ± 0.08 (1.55–1.87)1.71 ± 0.12 (1.50–1.87)0.150.53
BMI32.13 ± 6.71 (25–49.93)30.63 ± 6.23 (23.11–42.60)0.480.39

Upper eyelid and submental tissue USE, SE, and SWEI parameter measurements (mean ± SD, range), with associated levels of statistical significance

ParameterFES mean ± SD (range)Controls mean ± SD (range)Independent samples t-testp
EDT (mm)0.11 ± 0.08 (0.06–0.53)0.09 ± 0.03 (0.06–0.14)8.660.09
SFT (mm)0.09 ± 0.03 (0.03–0.20)0.07 ± 0.03 (0.04–0.12)2.120.74
OOT (mm)0.10 ± 0.03 (0.05–0.14)0.09 ± 0.04 (0.05–0.18)3.770.14
SFR1.33 ± 0.85 (0.36–2.70)1.36 ± 0.83 (0.73–3.38)−0.100.91
OFR1.05 ± 0.33 (0.53–1.75)1.12 ± 0.40 (0.63–1.83)0.670.34
ESW (kPa)11.99 ± 13.3 (2.30–61.21)6.53 ± 4.80 (3.67–22.00)0.230.97
FSW (kPa)9.82 ± 8.38 (2.50–38.16)7.09 ± 4.32 (3.58–19.00)3.650.40
OSW (kPa)10.81 ± 10.15 (3.02–43.57)5.00 ± 4.19 (1.45–18.60)2.640.04
TT (cm)4.37 ± 0.99 (2.83–6.05)4.33 ± 0.86 (3.60–6.10)−0.010.98
UAL (cm)3.95 ± 0.80 (2.81–6.05)5.57 ± 0.78 (2.72–6.45)−7.68<0.01
DOI: https://doi.org/10.15557/jou.2025.0019 | Journal eISSN: 2451-070X | Journal ISSN: 2084-8404
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Language: English
Submitted on: Mar 16, 2025
Accepted on: Jun 10, 2025
Published on: Jun 30, 2025
Published by: MEDICAL COMMUNICATIONS Sp. z o.o.
In partnership with: Paradigm Publishing Services
Publication frequency: 4 issues per year
Keywords:
high-frequency skin ultrasound,
strain elastography,
shear wave elastography,
floppy eyelid
Related subjects:
Medicine,
Basic medical science,
Basic medical science, other

© 2025 Vasilios Batis, Efstathios Detorakis, Sophia Schiza, Emmanuel Prokopakis, Konstantinos Krasagakis, Elena Drakonaki, published by MEDICAL COMMUNICATIONS Sp. z o.o.
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License.

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