 Good evening, everyone. Thank you, Dr. Petty. First of all, I would like to thank the committee, Dr. Crandall, Dr. Hoffman, Elaine, Dr. Petty, to allow me to make this presentation today. Today is my last day at the Mora Nye Center. So we do not have any disclosures. So the best phenomenon is palpibril oculogiaric reflex, which is a sign which is elicited when a patient is attempting to close the eye. The eyeball tends to roll up. Now, clinically, Bell's phenomenon plays a very important role in ophthalmology. And we routinely test for it, especially in cognac clinic, glaucoma clinic, before proceeding with any eyelid procedures in oculoplastics. Now, regarding Bell's phenomenon and considering how commonly it is performed, there is no uniform grading. We had a patient who had severe congenital ptosis in the clinic. And Adam Jorgensen was posted with me in oculoplastics when I had started here in my first week. So Dr. Petty asked us to examine him and tell him, tell us what his best phenomenon is. So Adam asked the patient to close his eyes forcefully. And he tried to open his eyelids and noted that there was a mild response. I went next into the room to examine the same patient. I asked the patient to gently close his eyes and opened his eyelid and noted the response to be poor. Now, both of us went, Dr. Patel, and told us our results. And Dr. Patel famously told us that you both have failed. So that was the third time we heard it that day. And Dr. Patel noted his response as neutral. Now, who is right? I'm quite sure you're going to say Dr. Patel. But let's see. So the best response in various papers has been described as mild response, poor response, good response, positive, negative. So why is it that a test that we routinely perform and we perform it the world over? And all institutions have so many implications in management of dry eyelid surgeries, knowing which drops can be given in a glaucoma patient. Why is it that we do not have a uniform grading for it? If you look at RAPD, if a doctor from Nepal is going to call you and tell you the patient has grade 3 RAPD, any of the homologists across the world will exactly know what that means and how the test might have been performed. If a doctor from Nigeria calls you up and tells you that on cover test, on cover test, alternate cover test, these are the squint findings of the patient, you will exactly know how the examination might have gone on. But that is not the case with Bell's Phenomenon. Now to truly understand any phenomenon or condition in medicine or surgery, it's very important to look back in history and read the chapters there. Now Charles Bell was a famed anatomist, surgeon and an artist. He had a facial palsy clinic which used to be quite famous in those days. It was he that first discovered and noticed Bell's Phenomen in one of his patients with Bell's palsy. He noticed that when the patient was trying to close his eyes, the eyeball rotated upward and outward. Now with Bell's, you would know that he did like naming things after himself and he described the long thoracic nerve, called it the Bell's nerve, he described Bell's palsy, the Bell Magendy Law and finally the Bell's Phenomenon. When he saw that in his patient, he performed a series of animal experiments in 1823. He first cut the superior rectus and rabbits and found that after a few moments, the animal could no longer voluntarily raise its eyeball. But on irritating the cornea, involuntary movement was still present and the eyeball still went up. Now being the researcher that he was, it is a little surprising to note that why he didn't proceed thinking on these lines as to why the eyeball rotated up and did the oblique have a role to play? And this particular century, we must remember that they still did not know the exact origin insertion nerve supply of ocular muscles and what actions they had on the eyeball. He further proceeded studying the ocular muscles and he looked at the obliques, the inferior and superior and different animals in cadaveric studies and he said that the oblique muscles did not control the normal position of the eyeball. So a landmark finding that could have been discovered long ago still remains unknown to us whether the oblique actually has a role to play in Bell's Phenomenon or not. Now Bell's Phenomenon is useful across medical practice of thermology, neuro of thermology, neurology in diagnosing or differentiating between various conditions. It has been described that this phenomenon is absent in 10% of normal individuals. In the earlier papers on Bell's Phenomenon, it is said that in early infancy this phenomenon is rare and as we age the response decreases but recent papers have contradicted that. It's interesting to note that Bell's can be elicited in some patients who have monocular elevation deficit and supranuclear defects. The largest paper, the largest study on Bell's Phenomenon was published in 73 by Ferrer et al. In which he described Bell's Phenomenon in these five groups with neurological disease, a group of normal individuals which he again subclassified into five groups according to their age, children with cerebral palsy, premature children and those with squint. 22% of the people in this combined study had a neutral response and the end conclusion of the study was he tried to convey the significance of this phenomenon in diagnosing neurological diseases. The Bell's Phenomenon is said to be rare in infants less than eight months but a Korean paper refuted this fact and found that Bell's Phenomenon can be elicited in young infants less than 32 weeks and approximately 77 to 92% of infants could show a good Bell's Phenomenon. It's commonly present in most people to the age of 30 and from the age of 30 to 50, it is said to be absent in 26% and one particular point that this paper makes that Bell's Phenomenon is absent in 66% over the age of 50 years made us rethink whether this finding is actually true because in our clinical experience that has not been the case. So the neural mechanism of Bell's unfortunately has still not been fully elicited despite the fact that it was described in 1823. So the seventh Korean non-nucleus, the third non-nucleus and the mesencephalic reticular nucleus all are supposed to play a role because of which the eye moves a certain way when somebody closes their eye. In 1979, a Japanese paper described three phases of Bell's Phenomenon. Initial, when the moment a patient, a person closes their eye, the eye moves upward or upward and inward. A static phase where it remains in that position followed by a final phase where it turns back from its upward position. Now the significant finding that this paper makes is that the tighter the blink, greater the amplitude. So what we need to remember and remind ourselves is that the amplitude of orbicularis contracture will have an effect on the Bell's Phenomenon that you will elicit. So we do know that the levator and the superior rectus, they both are supplied by the superior division of the third nerve. But what happens exactly when we blink? So this paper in 79 described exactly what happens when the blink, the spontaneous blink, with forced blink and electrically induced blink using electromyography. So it's interesting to note that in a forced eye closure, the electromyography study showed that there was an interruption in the levator activity with a sudden intensification in the activity of the superior rectus. Initially there was a slight delay in the orbicularis ocular activity and it suddenly showed a peak. In spontaneous blink, the entire response was similar, but the orbicularis activity was noted predominantly in the palpibril part and not its orbital part. And quite obviously, in patients with Bell's palsy, this response was muted or it was absent. Interestingly, for reasons even the authors could not explain why, in electrically induced blink, there was no change in the basal activity of superior rectus even though the blink could be elicited. Francis studied Bell's phenomenon in 508 consecutive patients and he described a detailed analysis and he divided the response into two. One is a small response, second is a normal response. The normal response was arbitrarily denoted by the longer arrow, which meant that the amplitude of eyeball movement was four millimeters or more. And the direction of the arrow showed the direction in which the eyeball moved. So now this study showed that the up response was seen in 84% patients, down in 8%, minimal response in 7%, horizontal in one. Interestingly, asymmetry between right and left was noted in 16% patients and 6% patients, they found it very difficult to classify because the response kept varying each time they repeated the test. Now how these authors examined the patients is they asked the patient to look straight, they held the lids of the patient between a thumb and their index finger and asked the patient to attempt high closure. So this is the way they documented the response that they found with arrows denoting the direction and the amplitude of response. Now this paper had 26 normal patients, basically they were asymptomatic despite the fact they had some degree of lag of thalmas. Among these patients, 27% patients showed mild to moderate ocular surface disorder in the form of punctate erosions, a past history of inferior keratitis, et cetera. Now in this study, up response of bells was noted in all patients except one in the subset of group. Now in 42 patients, the authors noted a down response. So basically in these patients at no time even on repeated testing, the eyeball never moved upwards. Now 17% of these patients had moderate to severe ocular surface disorders either at present or in the past and one patient actually had a conial ulcer severe enough that it led to evisceration later on. Now none of these patients had lag of thalmas. Now with this, the authors postulate that maybe the downward response may serve as a protective mechanism when the up response has failed to protect good ocular surface protection. And that your physiological integration of fragile mineral pain fibers with bells phenomenon may play a role here. And that the eyes and patient of lag of thalmas, they would indirectly show an upward bells phenomenon or maybe the bells phenomenon gets converted to become upward so that it serves to protect the cornea further. There have been four papers in literature that describe an inverse bells phenomenon that has been observed after levator desection. Now many of these papers are actually published in India and the other one and two others in Korea. The common features in these four papers is that all the patients had severe congenital ptosis with poor levator action. The surgery they underwent was a maximal levator advancement. They gave history of repeated ptosis correction in the past. And this phenomenon was a transient phenomenon that is ranging from a period of two weeks to six weeks after surgery, the bells reversed back to normal. And most of these were bilateral ptosis correction. So the mechanism that is postulated in these three papers is that the down response may serve as a protective reflex when after ptosis correction, there is severe lag of thalmas and the upper lid is not able to protect adequate cover for the cornea. The postoperative edema may alter certain dynamics between the superior rectus and the levator by causing enough edematous changes in the superior phonics. Now reversal of this phenomenon to up response may does make aberrant innervation an unlikely mechanism. Now the question that we raised is that does the method of eliciting bells phenomenon in the preoperative period, would that play a role in the imprecise interpretation of bells? Now the clinical methods for testing bells phenomenon I have already described. One is gentle lid closure and the other one is forced lid closure. And considering the fact that orbicularis indirectly will influence the amplitude of bells phenomenon, is there a way to test for the bells without having too much of influence of the orbicularis? So on further starting, we found this paper from 77 by Kohenital that describes bells phenomenon in a dark room using a transilluminator. So this is a transcutaneous transillumination test in which you place a light source near the lateral canthus of the eye. Once you get the red reflex in the pupil, you ask the patient to close the eye. And in patients who are light skinned, you can actually see and appreciate the red reflex through the skin. So this would negate any excess contraction of the orbicularis and the authors postulate that this is the ideal way to test a bells phenomenon. Well, there are still a lot of questions that had to be addressed. What is the ideal way to test a bells phenomenon? There is no established standard. There is no established grading. So among these three methods, what is the ideal method by which we can document this test? And do we know the relative number of normal, neutral and reverse bells phenomenon in a population based on a large study? The answer is no. 508 patients, normal individuals that Francis studied is the largest study in a normal population that we know of till date. Now what happens to bells phenomenon in presence of facial palsy? In the oculoplasty clinic, we have observed that patients with facial palsy do show an asymmetric response. And the side with the facial palsy actually has a less tendency to have a response as good as upward as the opposite. Now should we prospectively study all the patients who undergo ptosis repair, congenital adult ptosis, as well as patients who undergo repeated surgeries to see whether some of our patients end up developing a negative bells phenomenon. And why is it that only patients with severe ptosis or with poor levator action who have undergone repeated surgeries develop this? Is there a mechanism that still we do not know of? Now do the patients with negative or neutral bells truly have more dry eye symptoms than those with upturned bells? And all these findings could actually have a determining role in knowing how much skin you can excise or how aggressive you can be in upper and lower blepharoplasty. So the aim of our study is to study prospectively the bells phenomenon in 5,000 consecutive patients using various techniques and to accurately develop a grading system for it and to determine the most physiological method of testing this phenomenon and to look for a difference in symmetry in this phenomenon in patients with facial palsy. So we wish to propose a universal method of grading that can be adopted world over. The method which is simple and easily replicable by students and consultants alike. So for the grading system, we ended up studying bells phenomenon in 100 patients and it was tested using all three methods, a gentle lit closure, a forced lit closure and transillumination test. So this is the grading system that we propose. Grade zero is when the cornea does not move anywhere. The eyeball stays in the same position. Grade one is when in the undirated pupil, part of the pupil can still be seen. Grade two is when the pupil, the undirated pupil is no longer seen. Similarly, just the other way around, you have grade minus one and minus two in the down direction. So we included any individual with the ability to understand the test procedure. The exclusion criteria included people with strabismus who had a history of surgery for squint or any oculomotility disorder. So I'm gonna show you a video that we performed on a few people. You might recognize some of these people. So while performing the gentle light closure, it's important to do the test a little quick. You might have to repeat it because certain patients can be very sensitive and actually try to force close their eye. So definitely in her you can make out that the response with gentle closure was zero. While with forced closure, it went to plus one in the right and plus two in the left. Now in a completely dark room using transcutaneous ocular transillumination, you can see the red reflects in patients who are light skinned. You ask the patient to open, get a good red reflects in the pupil, ask them to close it, close the eye gently, and you can make out the red, you can follow the red reflects of the pupil through the skin of the eye. So in all 100 patients, we did notice considerable differences in the test performed in all three manner. Surprisingly in all 100 patients in whom we performed the light test, 99% patients showed a positive response. So in patients with a dilated pupil, the response is seen quite significantly. I'm not sure to what extent you're able to appreciate it in the video, but in the clinic when you demonstrate it, it is very relevant. In patients with dermatocleosis, it's important to raise the eyebrow and the excess fold of skin to know. So there was one patient that we found who actually had a very unusual response. So on gentle closure, you can see his bell says, I would put it as grade zero. And on first closure, it actually became minus one to minus two. Now this response was a little unusual. So we ended up documenting this response as we continued this study. And the range of, the age range of patients that we examined was from 19 to 93 years. There were 68 females and 32 males in the study. Now on light test, 70% patients showed an upward response measuring to grade one. On gentle closure, 43% patients showed either grade zero, minus one or minus two response. Now look at the pie chart of forced closure. 55% patients of the same group actually showed a grade two response. And the proportion of patient who showed a neutral response that is grade zero or minus one, minus two decreases significantly. Now among the patients who showed a negative response on gentle closure, only two patients showed a negative response on forced closure. So your response actually had become upward exaggerated by one or two grades. And in light test, as I mentioned, you only had one patient who had a negative response. Now in the study, we also looked at the direction of fire movement. But we found that the direction would not matter much. So long as the in, out or straight perverse direction will not matter. What matters is the direction in the vertical plane because that is what will determine the eyelid protection. So the reason for this study, as I mentioned, is to develop a universal method of grading which is simple, easily replicable. It's important to know that after years since Charles Bell described the Bell's phenomenon, we still do not know the pathway and need to study it further. Now the role of inferior oblique still remains unanswered. So the effects of Bell's in a patient with facial palsy and the position of a globe in a patient is sleeping needs to be assessed further. This will have implication in dry eye in deciding how far to raise the eyelid in tosses surgeries. And of course it has long term implications and lot of surgical decisions that we make. So I would like to finish my presentation by saying I would like to say huge thanks to Dr. Patel and his team who are welcoming to this family and the staff at Moran Eye Center because 70% of the people I examined were actually the staff here. I was the racist brown girl who was running around looking for white people. So the photography department, Randy Jim, they've always been there whenever I called them and all the patients who have been exceptionally warm and kind did not ask me any questions. Just let me examine them. Thank you.