Intraoperative visible iris sign detected during ptosis surgery in seven Korean patients who wore eye masks when sleep

Background: A visible iris sign (VIS) is the apparent visibility of iris color or contour through a closed upper eyelid in patients with aponeurotic ptosis from Western countries. This has been popularly reported in individuals from Western countries because the soft tissue of their lids is much thinner than that in individuals of Oriental descent. There is no report on VIS in individuals of Oriental descent preand intraoperatively. Objective: This study aimed to evaluate patients who wore eye masks when sleeping at night and assess the association between VIS and habitual wearing of sleeping mask while dissecting the eye lids to correct ptosis. Methods: Among the patients who visited the clinic for cosmetic blepharoplasty from 2018 to 2019, seven patients complained about the inconvenience of wearing eye masks for sleeping at night. Of these, two patients were diagnosed with pseudoptosis, and the others were diagnosed with aponeurotic ptosis preoperatively. Moreover, they presented with allergy, contact lens use, habitual eye rubbing, and dry eye syndrome. VIS was assessed preand intraoperatively, and preand intraoperative images were obtained. VIS was analyzed intraoperatively. Conventional blepharoplasty with ptosis correction was performed, and morphological characteristics of the lid layers were observed. Results: Preoperative VIS was not observed in all patients. However, positive intraoperative VIS was detected in six patients, which appeared as a black-colored region due to the defect from the orbital septum, aponeurosis, and Müller muscle. Five patients were diagnosed with aponeurotic ptosis. Moreover, two patients were finally diagnosed with subclinical aponeurotic ptosis because the anatomical defects were observed in these two patients who were preoperatively diagnosed with pseudoptosis. Conclusion: A sleeping eye mask was most likely used to decrease light transmission through the anatomical defects in patients with positive intraoperative VIS.