Hindawi

Disease Markers
Volume 2022, Article ID 8705436, 6 pages
https://doi.org/10.1155/2022/8705436

Research Article
Evaluation of Meibomian Gland Function after Therapy of Eyelid
Tumors at Palpebral Margin with Super Pulse CO2 Laser

Songjiao Zhao ,1 Jueni Duan ,2 Jing Zhang ,3 and Lan Gong 1,3

1
Department of Ophthalmology, Eye, Ear, Nose, & Throat Hospital of Fudan University, Shanghai 200031, China
2
Department of Physical Examination, Shenzhen University General Hospital, China
3
Department of Facial Plastic and Reconstructive Surgery, Eye, Ear, Nose, & Throat Hospital of Fudan University,
Shanghai 200031, China

Correspondence should be addressed to Jing Zhang; [email protected] and Lan Gong; [email protected]

Received 12 October 2021; Accepted 30 December 2021; Published 17 January 2022

Academic Editor: Ting Su

Copyright © 2022 Songjiao Zhao et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Purpose. To investigate the effect on meibomian gland function of super pulse carbon dioxide (CO2) laser excision in the
treatment of eyelid tumors at palpebral margin. Methods. 36 patients with 36 eyelid tumor size ≤ 1 cm and within 1 mm to
palpebral margin were recruited in this study. Of which, 16 cases with tumors in the upper eyelid and 20 cases in the lower
eyelid were involved. The eyelid tumors of all the patients were treated by super pulse CO2 laser with its power density varied
between 0.6 and 21.1 W/mm2 and in repeat mode. The laser spot size ranged from 120 to 200 μm. Ocular surface parameters
including tear film break-up time (BUT) and meibograde, meibum expressibility, and meibum quality were evaluated at
pretherapy, 1 week, 1 month, and 3 months posttherapy in all 36 patients. Result. All the patients were satisfied with the
therapy. No infective complications and recurrence occurred in any of the 36 patients at the following period. The eyelid
wound recovered well with nearly normal appearing after 2 to 3 weeks. The morphology of limbi palpebralis, BUT,
meibograde, meibum expressibility, and meibum quality of all the 36 patients showed no significant difference before and after
the therapy. Conclusions. Super pulse CO2 laser had no effect on meibomian gland function and morphology in the excision of
tumors at palpebral margins, which was an efficacy and well-tolerated therapy with lower complications and recurrence.

1. Introduction eyelid benign tumors for the shortened exposure time and
reduced thermal damage [1, 4–6].
Eyelid benign tumors are common cosmetic concerns and Meibomian gland is a critical sebaceous gland that is
traditionally treated by surgical excision in daily ophthal- located in the superior and inferior tarsal plates and opened
mology practice. However, specific surgical difficulties and at the palpebral margin. The meibum is delivered from the
complications such as eyelid deformity and scar formation opening to the ocular surface to maintain the tear film stabil-
following surgery should be considered in tumors located ity and ocular surface homeostasis [7]. Hyposecretion or
at palpebral margin. Laser therapy, for instance, carbon obstruction would affect meibomian gland function, even
dioxide with infrared source (CO2, 10600 nm) [1], erbium leading to meibomian gland dysfunction. Several iatrogenic
yttrium aluminum garnet laser (Er:YAG, 2790–2940 nm) conditions such as eyelid surgery and cosmetic procedures
[2], and argon laser (Ar, 488–514 nm) [3] has been widely were identified and reduced the outflow of lipid secretion
used and demonstrated superior to traditional surgery in because of inadequate gland squeezing, inflammatory
the treatment of eyelid tumor for the shorter operation time, obstruction of the opening, and even complete loss of mei-
less pain, no bleeding, mild postoperative reaction, no scar, bomian gland [8–10]. Although super pulse CO2 laser has
satisfactory healing result, and good acceptable by patients. been demonstrated superior to other traditional lasers, it
The application of CO2 laser in a super pulse model has been has been reported to form atrophic scarring at the treated
proved effectively and predominantly in the treatment of lesion [4]. Furthermore, the safety and efficacy of super pulse
2 Disease Markers

(a) (b) (c)

Figure 1: Pigmented nevus located at palpebral margin and close to the papilla: (a) before the laser therapy, (b) just after the laser therapy,
and (c) 1 month after the laser therapy.

CO2 laser in therapy of tumor at palpebral margin has not 200 μm) was used to photocoagulate the margin and bottom
been investigated. Considering that eyelid tumor at palpe- of the treated area to form a shallow pit. Histopathological
bral margin is generally colocalized with the opening of mei- examination was performed for the resected tumors with
bomian gland, we wondered whether the inflammation or sufficient residual tissue. Topical chlortetracycline ointment
scar formation of palpebral margin following super pulse was used immediately after the treatment. Patients were
CO2 laser excision would have effect on meibomian gland informed to keep the treated area dry until the crust desqua-
function. mated and fell off. Figure 1 shows the picture of pigmented
In this study, we investigated the effect of super pulse nevus before and after super pulse CO2 laser treatment.
CO2 laser excision on meibomian gland function in the
treatment of eyelid tumors at palpebral margin. The safety 2.4. Tear Film Break-Up Time (BUT). A minimal volume
and cosmetic effect of super pulse CO2 laser was also fluorescein was instilled into the lower fornix of patients using
evaluated. the fluorescein strips (Jingming, Tianjing, China). The
patients were requested to blink several times naturally and
then look straight and keep eyes open, until the first dry spots
2. Methods on the cornea surface appeared under the cobalt blue light of
2.1. Patients. Thirty-six patients who underwent super pulse the slit lamp. The time (seconds) from the last blink to the first
CO2 laser-assisted benign eyelid tumor excision at the Eye, appearance of dry spots was recorded as BUT. This procedure
Ear, Nose and Throat Hospital of Fudan University, from was repeated for three times.
May 2020 to March 2021, were recruited in this study. Writ-
2.5. Meibograde. Meibographies of the upper and lower eye-
ten informed consent was obtained from all the participants.
lids were captured by the Oculus Keratograph 5 M (Wetzlar,
The exclusion criteria included premalignant lesions, large
Germany), and the meibomian gland dropout rate was ana-
lesions (diameter > 1 cm), and blepharitis. The study con-
lyzed qualitatively by ImageJ software (National Institutes of
formed to the Declaration of Helsinki and was approved
Health, USA). Meibograde of each eyelid was graded based
by the ethics committee of the Eye, Ear, Nose, and Throat
on the meibomian gland dropout as 0-3: 0, no dropout of
Hospital of Fudan University (2016034).
meibomian gland; 1, dropout was less than one third of the
meibomian gland; 2, dropout was between one third and
2.2. Data Collection and Ocular Examination. General oph-
two thirds of the meibomian gland; and 3, dropout was over
thalmologic examination including visual acuity, intraocular
two thirds of the meibomian gland. Meibogrades of the
pressure, anterior segment and fundus, and eyelid examina-
upper and lower eyelid were summed to grade as 0-6 for
tion was performed before treatment. Age, gender, operated
each eye (Figure 2).
eye and eyelid, the number of lesions, and the size of lesions
were collected. All the patients received ocular surface exam- 2.6. Meibomian Gland Function. The assessment of meibo-
ination including tear film break-up time (BUT), meibo- mian gland function was under slitlamp using a grade
grade, and meibomian gland function before treatment and method considering meibomian gland expressibility, mei-
1 week, 1 month, and 3 months after treatment. Intraopera- bum quality, and lid margin changes. Over 8 meibomian
tive and postoperative complications or recurrence were also glands of laser treated eyelid were digitally pressed, and the
recorded. meibum expressibility was graded as 0-3: 1, light; 2, moder-
ate; and 3, heavy pressure, as well as the quality of meibum
2.3. Super Pulse CO2 Laser-Assisted Eyelid Tumor Excision. was graded as 0-3: 0, clear; 1, cloudy; 2, granular; and 3,
All the patients underwent super pulse CO2 laser-assisted toothpaste. Based on the irregularity of the lid margin, telan-
eyelid tumor excision by the same senior oculoplastic sur- giectasia, plugging of meibomian orifices, and replacement
geon (Jing Zhang) under topical anesthesia with 2% lido- of the mucocutaneous junction, lid margin changes were
caine. A corneal protection plate was used to prevent graded as 0-4.
ocular injury. The lesion basement was excised using a
CO2 laser (wave length: 10600 nm; power density: 0.6- 2.7. Statistical Analyses. Data analyses were performed using
21.1 W/mm2; exposure time: 0.05 seconds) with the help of Graphpad Prism 9 software (USA). The results are expressed
a biopsy forceps. Then, a larger spot of CO2 laser (150- as the mean ± standard deviation. Chi square test was used
Disease Markers 3

(a) (b) (c)

Figure 2: Meibographies of the upper and lower eyelids showing different meibomian gland dropouts: (a) less than one third at both upper
and lower eyelids, (b) between one third and two thirds at both upper and lower eyelids, and (c) over two thirds at both upper and lower
eyelids.

Table 1: Demographic and preoperative characteristics. Table 2: The histopathological diagnosis of the benign eyelid
lesions treated with CO2 laser.
Characteristics n = 36
Age (mean ± SD) 38:1 ± 15:3 Histopathological diagnosis N = 32 (100%)

Sex, n (%) Pigmented nevus 13 (40.6%)

Male 11 (30.6%) Squamous papilloma 11 (34.4%)
Female 25 (69.4%) Intradermal nevus 4 (12.5%)
Laterality, n (%) Xanthelasma palpebrarum 2 (6.3%)
Left 20 (55.6%) Viral wart 1 (3.1%)
Right 16 (44.4%) Dermis collagen fiber hyperplasia 1 (3.1%)
Eyelid, n (%) Histopathological diagnosis was clarified in 32/36 patients
(88.9%).
Upper 16 (44.4%)
Lower 20 (55.6%)
Size of lesions, n (%) The wound healing was satisfactory in all the 36 patients
≤5 mm 24 (64.8%) without any infection. None of the patients were compli-
5-10 mm 13 (35.2) cated by lid notching, entropion, or ectropion. Eyelash loss
BUT (s, mean ± SD) 5:4 ± 2:8 was occurred in 4 patients (11.1%) with lesions larger than
Meibograde (mean ± SD) 2:9 ± 1:0 5 mm. Transient hypopigmentation was occurred in 3
patients (8.3%). No distinctive hyperpigmentation, scar
Meibum expressibility (mean ± SD) 1:9 ± 0:9 hypertrophy, blistering, or swelling at the treated areas. No
Meibum quality (mean ± SD) 1:6 ± 0:9 systematic complications or recurrence was observed in the
BUT: tear film break-up time following period or recurrence.
Histopathological diagnosis was clarified in 32 patients
(88.9%). Pigmented nevus (n = 13, 40.6%) and squamous
to compare BUT, meibograde, meibum expressibility, and papilloma (n = 11, 34.4%) were the two primary types,
meibum quality before and after treatment. followed by intradermal nevus (n = 4, 12.5%), xanthelasma
palpebrarum (n = 2, 6.3%), viral wart (n = 1, 3.1%), and der-
mis collagen fiber hyperplasia (n = 1, 3.1%) (Table 2).
3. Results After the CO2 laser treatment, BUT did not significantly
changed in eyes with upper or lower eyelid tumors
A total of 36 patients (36 eyes with 36 eyelid tumors) that (Figure 3(a)). Compared with the meibograde and meibum
underwent super pulse CO2 laser-assisted eyelid tumor exci- expressibility from the pretreated values, no significant dif-
sion were included, with 11 males and 25 females. The mean ference was found at any follow-up time in eyes with upper
age at the time of therapy was 38:1 ± 15:3 years (range from or lower eyelid tumors (Figures 3(b) and 3(c)). The lid mar-
11 years to 65 years). The tumors were primarily located at gin changes showed an insignificant increase at 1 week post-
the left eye (n = 20, 55.6%), and the lower eyelid was more therapy and returned to the basal level at 1 month
involved (n = 20, 55.6%). The lesion size was 1 cm at most, posttherapy in eyes with lower eyelid tumors (Figure 3(d)).
including 24 lesions ≤ 5 mm and 13 lesions > 5 mm. Before Although the score of meibum quality gently increased after
the CO2 laser treatment, the mean values of BUT, meibo- the treatment, the changing trend was not statistically signif-
grade, meibum expressibility, and meibum quality in the icant in eyes with both upper and lower eyelid tumors
treated eyes were 5:4 ± 2:8 s, 2:9 ± 1:0, 2:9 ± 1:0, and 1:6 ± (Figure 3(e)). The super pulse CO2 laser treatment in upper
0:9, respectively (Table 1). and lower eyelid tumors showed no significant difference.
4 Disease Markers

ns ns
10 5
ns ns

Meibograde (score)
8 4
6 3

BUT (s)
4 2
2 1
0 0
Upper eyelid Lower eyelid Upper eyelid Lower eyelid
Pre-tr Post 1 mo Pre-tr Post 1 mo
Post 1 we Post 3 mo Post 1 we Post 3 mo
(a) (b)

ns ns ns
3 ns

Lid margin changes (score)

Meibum expressibility (score)

2
2

1
1

0
0
Upper eyelid Lower eyelid
Upper eyelid Lower eyelid
Pre-tr Post 1 mo
Pre-tr Post 1 mo
Post 1 we Post 3 mo
Post 1 we Post 3 mo
(c) (d)
ns
3 ns
Meibum quality (score)

0
Upper eyelid Lower eyelid

Pre-tr Post 1 mo
Post 1 we Post 3 mo
(e)

Figure 3: Changes in tear film parameter and meibomian gland function after super pulse CO2 laser therapy. Evaluation of the BUT (a),
meibograde (b), meibum expressibility (c), lid margin changes (d), and meibum quality (e) at pretherapy and posttherapy in the eyes
with upper or lower eyelid tumors. No significant differences were found at any follow-up time compared to the pretreated values. The
super pulse CO2 laser therapy showed no significant difference between upper and lower eyelid tumors.

4. Discussion gland. Traditional surgical excision of tumors at palpebral

margins was a challenge because of the complications such
This study demonstrated that super pulse CO2 laser excision as scar hypertrophy, eyelash loss, and angulation deformity,
showed no significant effect on meibomian gland function in leading to patients’ dissatisfaction.
therapy of eyelid benign lesions at palpebral margin, serving Advancement of laser technology in recent two decades
as a safe and effective alternative therapeutic modality of tra- has increased options for eyelid benign tumor treatment,
ditional surgical excision. which achieved precise tissue damage by using appropriate
Eyelid benign tumors accounted for nearly 80% of eyelid wavelength and pulse duration of laser energy [12]. Compar-
tumors, and not a few proportion was existed at palpebral ing with other laser therapy, super pulse CO2 lasers enables
margins in different types of pathology [11]. The palpebral hemorrhage-free noncontact incisional excision and that
margin is a complex structure with eyelash follicles and exo- producing superior tissue contraction and hemostasis, espe-
crine gland located such as meibomian gland and sebaceous cially in the deeper lesion removal [2]. For tumors with
Disease Markers 5

special location such as palpebral margins, CO2 laser surgery 5. Conclusion

keeps the margins in their anatomical position so that entro-
pion or ectropion is not to be reckoned with, showing Our study identified that super pulse CO2 laser had no effect
advantageous in preserving patients’ appearance with com- on meibomian gland function and morphology in the exci-
plete morphology of palpebral margin [1, 5, 13]. sion of tumors at palpebral margins, which was an efficacy
Although CO2 laser therapy exhibits more thermal and well-tolerated therapy with lower complications and
necrosis and slower wound healing times that would be recurrence.
accompanied by the longer inflammatory reaction [12], the
satisfactory therapeutic and cosmetic results with reduced Data Availability
complications and recurrence rate were confirmed by
numerous studies in eyelid benign lesions [1, 4, 5, 14–17]. The datasets used and/or analyzed during the current study
Consistent with our previous reports, this study also are available from the corresponding author on reasonable
identified the good clinical response of super pulse CO2 request.
laser in excision of eyelid benign tumors without any
recurrence in the follow-up period [1, 13]. Here, the orig- Conflicts of Interest
inal contribution was to further investigate the potential
The authors declare that the research was conducted in the
effects of super pulse CO2 laser on the meibomian gland.
absence of any commercial or financial relationships that
Meibomian glands are distributed on the posterior edged
could be construed as a potential conflict of interest.
of the palpebral margin, participating in the ocular surface
homeostasis [7]. Persistent inflammation of eyelid margin
or ocular surface might lead to the infiltration of inflam- Authors’ Contributions
matory cells in the surrounding microenvironment that Songjiao Zhao and Jueni Duan have contributed equally to
serves as an inflammatory form of meibomian gland dys- this work. Jing Zhang and Lan Gong have contributed
function [18]. Ocular surgeries such as cosmetic blepharo- equally to this work and share last authorship.
plasty and cataract have been demonstrated to effect on
meibomian gland function owing to direct damage or ocu-
lar surface inflammation [19, 20]. In the super pulse CO2
Acknowledgments
laser therapy of eyelid benign tumors at palpebral margin, We would like to thank Xiaozhao Zhang for her help in data
the intensive heat generated by CO2 laser directly destroys collection. This work was supported by the Natural Science
the surrounding tissue of the lesions. The local and adja- Foundation of China (NSFC) (82070924).
cent meibomian gland might be potentially affected due
to the inflammatory cells infiltration or thermal injury of References
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