[A case of amyotrophic lateral sclerosis/frontotemporal lobar degeneration with apraxia of eyelid opening]

We report the case of a 76-year-old man with apraxia of eyelid opening (AEO) and amyotrophic lateral sclerosis with dementia (ALS-D)/frontotemporal lobar degeneration with motor neuron disease (FTLD-MND). The initial symptom was AEO. Neurological examination revealed mainly bulbar symptoms with a neurogenic pattern on needle electromyograms of the tongue muscles and the biceps muscles. Furthermore, he developed severe dementia with frontal lobe dysfunction and progressive non-fluent aphasia. Brain magnetic resonance imaging revealed severe cerebral atrophy and leukoaraiosis in the bilateral frontal lobes and the anterior part of the bilateral temporal lobes; brain 99mTc ethyl cysteinate dimer single photon emission computed tomography (ECD SPECT) showed hypoperfusion in the same areas. The patient showed improvement in stereotyped behavior and AEO after treatment with 50 mg/day of fluvoxamine maleate (the initial dose was 25 mg/day). Because serotonin receptors are markedly reduced in the frontal and temporal cortexes of patients with FTLD, we considered that dysfunction of the serotonergic system in the frontotemporal lobe caused AEO. Considering the findings of this case along with those of previous reports, we propose that there is a relatively homogeneous development of ALS-D/FTLD-MND with AEO.

Evaluation and management of unilateral ptosis and avoiding contralateral ptosis

Treating unilateral ptosis can be challenging and a proper preoperative evaluation may help prevent unexpected outcomes on the contralateral lid. Preoperative evaluation should include testing for Hering's law, which remains useful in understanding the phenomenon of induced contralateral eyelid retraction in the context of ptosis. Approximately 10% to 20% of patients with unilateral ptosis have some degree of induced retraction on clinical evaluation in the contralateral lid. When there is a positive Hering's test on preoperative examination, the surgeon should consider a bilateral ptosis procedure. The surgical approach to unilateral ptosis depends on the severity of the ptosis and its etiology, and the surgeon should be aware of which procedure is most likely to provide the best outcome in selected instances.

Levator plication versus resection in congenital ptosis - a prospective comparative study

PURPOSE

To compare levator plication with resection in congenital ptosis.

METHODS

Prospective comparative randomized trial involving 20 eyes of 20 patients with age > 4 yrs, simple mild-to-moderate congenital ptosis with good-to-fair amount of levator action were included. Patients were randomized to either levator resection or plication. Outcome was compared in terms of eyelid height and course of postoperative events. Data was compared using the paired and unpaired t-test.

RESULTS

The mean M.R.D. 1 at the end of 3 months in Group A was 2.8 +/- 1.23 mm and in Group B was 1.12 +/- 0.83 mm (p value = 0.001). Plication did not improve levator action much. Resection lead to more alterations in Bell's, lid lag, lagophthalmos and persisting edema (3 cases).

CONCLUSION

In 70% cases of congenital ptosis, good cosmetic outcome can be achieved with levator resection. With levator plication there are greater chances of drooping from fourth week onwards. The technique of plication, though simpler in approach failed to correct dystrophic muscle in congenital ptosis.

Abnormalities induced in reciprocal inhibition between orbicularis oculi and levator palpebrae following peripheral facial palsy

Peripheral Facial palsy (PFP) is generally considered a benign condition with good recovery and no sequelae. Yet, a distortion in the gesture and abnormal blinking, as those typically found in blepharospasm, can potentially develop early on. Such abnormal movements seem to be related to remodelling mechanisms that take place in the process of recovery. We report 2 cases where such clinical features became evident following an idiopathic PFP, as a result of reciprocal inhibition of orbicularis oculi and levator palpebrae. Hence, the neurophysiological study revealed an increased frequency in the blinking, with bilateral trigeminal-facial facilitation and, most notably, a disturbance that only became evident when the eyes were maintained wide open. Interestingly, those features were not reproduced in other tasks where the blinking conditions had not been altered. Our findings suggest that sensory inputs (reflex afferent pathways) are involved in such abnormal movements. The insufficient eyelid closure (lagophthalmus) in the context of PFP is likely to account for the exaggerated corneal vulnerability, thus resulting in abnormal mechanisms of adaptation.

Combination of periocular myocutaneous flaps for one-stage reconstruction of extensive defects of the eyelid

We present the reconstructive challenge after excision of a large periocular tumour in a patient who needed early visual rehabilitation. The periocular full thickness deficit of his only sighted eye was reconstructed with a combination of periocular myocutaneous flaps and a free buccal mucosal graft. Adequate functional and cosmetic results with early visual rehabilitation were achieved in a single procedure.

Stability of silicone band frontalis suspension for the treatment of severe unilateral upper eyelid ptosis in infants

PURPOSE

To address the efficacy, safety, and stability of frontalis suspension of the upper eyelid with a silicone band for the treatment of severe congenital ptosis in infants.

METHODS

Data from 22 pediatric patients undergoing unilateral frontalis suspension with silicone band were retrospectively reviewed with a follow-up ranging from 18 to 30 months. The margin-reflex distance (MRD) and the corneal staining had been evaluated at each pre- and postoperative visit. Data were analyzed by analysis of variance and t test for paired data.

RESULTS

MRD was absent before surgery in all cases: it ranged from -1 mm to -4 mm (-2.4+/-0.8 mm). Immediately after surgery, it increased to 2.9+/-0.3 mm, and then progressively reduced by 0.6 mm within the first 3 months (p=0.001); a further reduction of 0.2 mm, occurring between 3 and 12 months after surgery, was not statistically significant. After the 12-month visit, no changes in MRD were found at follow-up for any patient. Corneal staining, which was present in five patients over the first 2 postoperative weeks, recovered without sequelae. Complications occurred in three eyes: overcorrection and corneal ulcer in one case requiring removal of the silicone band, one granuloma, and one extrusion of the silicone band from the upper frontal incision.

CONCLUSIONS

During the study period, the frontalis suspension with a silicone band was an effective and safe procedure. MRD values were stable between month 3 and the end of follow-up, although this series does not preclude the possible occurrence of blepharoptosis at longer time intervals.

Levator superioris muscle function in involutional blepharoptosis

PURPOSE

To assess the role of muscular degeneration, we evaluated the correlation between ptosis severity and levator muscle function.

DESIGN

Retrospective cohort study.

METHODS

The medical records of 136 patients (53 men and 83 women; mean age, 67 years) with acquired blepharoptosis were reviewed for levator function (LF), margin reflex distance (MRD), age, and gender. Multivariate linear regression was performed for statistical analysis.

RESULTS

A significant correlation (P < .001) was seen between MRD (mean, 1.0 + 1.0 mm; range, -3.0 to 3.0 mm) and LF (mean, 15.0 + 1.0 mm; range, 11.0 to 20.0 mm). On average, a 0.5-mm reduction in LF was observed for each 1.0-mm decrease in MRD. This was independent to other variables assessed.

CONCLUSIONS

In patients with involutional blepharoptosis, a directly proportional decrease in levator function and eyelid height was observed. This may implicate an abnormality of the levator muscle itself as a contributing factor in the development of involutional blepharoptosis.

Use of the orbicularis retaining ligament in lower eyelid reconstruction

INTRODUCTION

The orbicularis retaining ligament (ORL) is a distinct anatomical structure that has only been recently characterised. A variety of techniques, based on Hamra's concepts, now divide this ligament during lower lid blepharoplasty. This often produces a substantial skin excess which is discarded. We set out to investigate the validity of this surgical manoeuvre as a means of recruiting anterior lamella for the purposes of lower lid reconstruction.

MATERIALS AND METHODS

Between September 2002 and August 2004, 23 patients underwent reconstruction of the anterior lamella of their lower eyelid using this technique. The mean age of the patients was 56 years (range 26-86 years). The mean follow-up time was 20 months (range 12-36 months). Clinical evaluation was carried out preoperatively and postoperatively to assess the presence of palpebral non occlusion, epiphora, the sensation of a dry eye, ectropion, conjunctivitis and keratitis. Assessment of the tissue deficit was made clinically and with standardised digital photographs.

RESULTS

Satisfactory reconstruction of the anterior lamella of the lower eyelid was achieved in 19/23 patients. Preoperative symptoms of epiphora and lower lid position were improved. The visual analogue scale of appearance was improved postoperatively. In some cases, particularly in the atrophic lower lid, the results were short lived and further surgery was required to achieve optimal results.

CONCLUSION

In cases of isolated cutaneous deficit where the lid support mechanisms are intact, the procedure is both successful and aesthetically favourable for resurfacing this challenging area.

Apraxia of eyelid opening after subthalamic deep brain stimulation may be caused by reduction of levodopa

Apraxia of eyelid opening (ALO) is an infrequent side effect of deep brain stimulation (DBS) of the subthalamic nucleus (STN) for Parkinson's disease (PD). However, the pathogenesis of ALO after STN DBS is not well understood. We report on two patients who suffered from disabling ALO after bilateral STN DBS. Their ALO improved by resuming the levodopa medication that had been discontinued after the surgery. Although ALO after STN DBS is considered as an adverse effect of STN stimulation, postoperative modification of dopaminergic medication may be a cause of ALO after STN DBS.

Floppy Eyelid Syndrome

PURPOSE

To evaluate the change in upper eyelid position after horizontal surgical tightening in patients with floppy eyelid syndrome.

DESIGN

Prospective, noncomparative, interventional case series.

PARTICIPANTS

Eighteen patients with a clinical diagnosis of floppy eyelid syndrome.

METHODS

Horizontal surgical tightening of the upper eyelid was performed by full-thickness wedge resection in 24 eyelids of 18 patients with floppy eyelid syndrome. Preoperative and postoperative upper eyelid position as measured by the margin reflex distance (MRD) was assessed. Student's paired t test then was used to analyze the change in upper eyelid position after horizontal tightening alone of floppy upper eyelids.

MAIN OUTCOME MEASURES

Change in upper eyelid MRD after surgery.

RESULTS

Preoperative MRD ranged from -0.5 to 4.0 mm, with a mean of 1.9 mm (+/-1.3 mm, standard deviation [SD]). Postoperative MRD ranged from 0.5 to 6.0 mm, with a mean of 3.2 mm (+/-1.4 mm, SD). The change in MRD ranged from -0.5 to 2.5 mm, with a mean of 1.3 mm (+/-0.7 mm, SD; P<0.001).

CONCLUSIONS

Horizontal upper eyelid tightening alone generally results in secondary improvement of the ptosis associated with floppy eyelid syndrome.

Unusual focal ictal pattern in children with eyelid myoclonia and absences

Eyelid myoclonia is a type of epileptic seizure characterized by marked jerking of the eyelids, often associated with jerky upward deviation of the eyeballs. It can be triggered by eye closure. The ictal electroencephalographic pattern of eyelid myoclonia consists of generalized polyspike waves at 3 to 6 Hz. Eyelid myoclonia can be a component of the clinical seizures seen with idiopathic, symptomatic, or cryptogenic generalized epilepsy. The objective of this study was to describe the unusual focal ictal electroencephalogram features of two patients with developmental delay and eyelid myoclonia. To the best of our knowledge, this unique electroencephalogram finding was not previously described.

Objective measurements of lower-level visual stress

PURPOSE

To determine the sensitivity of the electromyography (EMG) response of the orbicularis oculi muscle to selected lower-level visually stressful conditions to establish the extent to which it can be used as a measure of visual discomfort.

METHODS

Thirty-one subjects (18 years or older) with 20/20 vision, without history of ocular pathology, oculomotor limitation, or cognitive deficits participated in the study. Subjects read on a computer display for 27 trials of 5 min duration under different low-level asthenopic conditions. The conditions were graded levels of font size, font type, contrast, refractive error, and glare. Orbicularis oculi activity was recorded using surface EMG. Blink-free epochs of EMG data were analyzed for power for all the conditions. Blink rate for all the trials was also measured. At the end of each trial, subjects rated the severity of visual discomfort experienced while reading.

RESULTS

Conditions that benefit from squint (refractive error and glare) showed increased EMG power (p < 0.001) from the orbicularis and increased blink rate (p = 0.002), whereas those that do not benefit from squint (small font and low contrast) showed no significant EMG response and a significant decrease in blink rate (p = 0.003 and p = 0.01). All conditions resulted in significant visual discomfort; the p value for font type was 0.039 and p < 0.001 for the other conditions.

CONCLUSIONS

The results suggest that the squint-beneficial conditions are operated by a local mechanism involving contraction of the orbicularis and increase in reflex blinking, whereas those that do not benefit from squint do not engage the orbicularis and decrease blink, possibly through central inhibition of spontaneous blinking. The EMG response is a sensitive objective measure for the squint-beneficial conditions. However, for the non-squint-beneficial conditions, blink rate may be a more sensitive objective measure, although EMG with longer trial durations should be tested.

Transblepharoplasty Ptosis Repair: Three-Step Technique

BACKGROUND

The ability to predict postoperative lid levels in ptosis surgery has been refined over the years, but there is no completely predictable formula with which to predict the final tension in the upper lid that determines the final upper lid level. A significant percentage of patients continue to require postoperative surgical revision. The authors studied the effectiveness of a technique for the quantitation of aponeurotic repair that is not a measured resection procedure, does not require voluntary patient cooperation, and can be performed under general anesthesia.

METHODS

The surgical technique involves reapproximation of specific anatomical landmarks, adjustment of upper lid level by eyelid gapping, and adjustment of upper lid tension with a spring-back test. Consecutive patient charts were reviewed retrospectively for age, sex, clinical examination, levator function, and outcomes, including revision rate and patient satisfaction. A total of 144 procedures were performed for 80 patients (64 bilateral and 16 unilateral). The series was reported for a 3-year period (2002 through 2005). The mean age was 62 years (range, 40 to 85 years). The average follow-up was 18 months. All patients had acquired adult ptosis with levator dehiscence and good levator function.

RESULTS

The criterion for surgical revision was a greater than 1-mm asymmetry between the eyelids or patient dissatisfaction. Twelve patients (15 percent) were considered to be slightly asymmetric postoperatively, but only two (2.5 percent) exceeded the criterion and required surgical revision in the early postoperative period (<1 year).

CONCLUSION

Tarso levator surgery can be performed under general anesthesia using a three-step technique to correct ptosis with a superior predictability.

Use of the Levator Muscle as a Frontalis Sling

PURPOSE

To investigate the use of the distal portion of levator aponeurosis as a flap for frontalis suspension in patients with severe congenital ptosis and poor levator function.

METHODS

Eleven procedures were performed on 8 patients with severe congenital ptosis and poor levator muscle function. Three of the 8 patients had Marcus-Gunn jaw-winking phenomenon. Preoperative evaluation included measurements of the degree of ptosis, levator function, superior rectus action, Bell phenomenon, lagophthalmos, and (if present) synkinetic eyelid movement. Surgery involved fashioning a flap from the distal portion of the levator aponeurosis and anchoring it to the frontalis muscle. Postoperatively, patients were followed for at least 6 months to assess the level of the eyelid in the primary position at rest and when the brow is raised, the degree of eyelid margin excursion on brow elevation, persistence of synkinetic eye movement, presence of complications, lagophthalmos, corneal exposure, and symmetry.

RESULTS

Synkinetic muscle movements were completely abolished. All cases had good primary eyelid position, no corneal complications, and effective frontalis action on eyelid elevation.

CONCLUSIONS

The distal levator muscle flap is an effective frontalis suspension material to correct ptosis with poor levator function and to abolish synkinetic eyelid movement without compromising corneal protection.

A randomized clinical trial of two methods of fascia lata suspension in congenital ptosis

PURPOSE

To compare the results of 2 methods of upper eyelid sling placement with autogenous fascia lata in the treatment of congenital ptosis.

METHODS

In a randomized clinical trial, patients with congenital upper eyelid ptosis and poor levator function (<4 mm) were randomly assigned to either of 2 methods of upper eyelid sling placement: group A, bitriangular fascia sling (modified Crawford method), and group B, monotriangular fascia sling (modified Fox method).

RESULTS

This study included 30 upper eyelids (15 eyelids in each surgical group) of 19 patients (8 unilateral and 11 bilateral cases) with congenital ptosis. Mean increase in eyelid fissure height was 2.7 +/- 2.3 mm in group A and 3.4 +/- 2.2 mm in group B. Change in eyelid fissure in both groups was significant (p < 0.001, paired t test) but the intergroup difference was not (p = 0.4, independent sample t test). Early complications such as corneal epithelial defects and entropion and late complications such as undercorrection were comparable in the 2 groups. No patient experienced recurrent ptosis requiring reoperation in either group.

CONCLUSIONS

The monotriangular method of upper eyelid fascia sling placement can be used instead of the more popular bitriangular method. Advantages include less need for fascial tissue, less periocular scar formation, and a shorter period of anesthesia.

Eyelid Squint Response to Asthenopia-Inducing Conditions

PURPOSE

To study the orbicularis oculi muscle response to asthenopia-inducing conditions.

METHODS

Twenty subjects (18-36 years) screened for 20/20 vision in each eye participated in the study. Subjects read passages under different asthenopia-inducing conditions. The inducing conditions were glare, low contrast, small font size, refractive error, up gaze, accommodative stress and convergence stress. Surface electromyography (EMG) was used to study the orbicularis oculi response from the right eye. Palpebral fissure height was measured from recorded video images of the right eye. At the end of each condition subjects were asked to rate the severity and type of visual discomfort experienced.

RESULTS

Outcome measures for the asthenopia-inducing conditions were compared with their respective nonstress controls. Repeated measures analysis of variance was used to analyze the data. Refractive error (p = 0.0001), glare (p = 0.0001), low contrast (p = 0.007), small font (p = 0.034), and up gaze (p = 0.001) resulted in a significant increase in EMG power. Refractive error (p = 0.0001) and glare (p = 0.0001) also caused significant reduction in aperture size. Reading a low contrast text caused a reduction in blink rate (p = 0.035), whereas refractive error (p = 0.005) and glare (p = 0.01) caused an increase in blink rate. All conditions induced significant visual discomfort (p < 0.001).

CONCLUSION

Refractive error and glare, which reduce image quality and benefit from eyelid squint, caused increased EMG power, eyelid squint response and increased blink rate. Low contrast and small font, which reduce image quality but do not benefit from eyelid squint, resulted in increased EMG power without changes in aperture size and reduced blink rate (for low contrast). Accommodative and convergence stress (in subjects with normal accommodative and vergence abilities) did not cause changes in EMG power, aperture size or blink rate. These results suggest that contraction of the orbicularis oculi is a part of the asthenopia mechanism related to compromised image quality.

Clinical effects of conjunctiva-Müller muscle resection in anophthalmic ptosis

Purpose

To evaluate the clinical effects of conjunctiva-Müller muscle resection through conjunctival incision in anophthalmic patients with mild ptosis.

Methods

Conjunctiva-Müller muscle resection was performed by one surgeon in 8 patients (8 eyes) who had received evisceration or enucleation and responded to 10% phenylephrine solution to correct ptosis. The average age of the patients was 35.87±13.4 years. Ptosis was seen from 1 to 34 months after evisceration or enucleation. The preoperative MRD 1 was -2 to 0.5 mm (average : -0.25±1.10 mm) and the difference of MRD 1 between before and after 10% phenylephrine use was 2.56±0.98 mm. The Müller muscle was resected 7.5 to 9 mm through conjunctival incision during surgery to match the MRD 1 of sound eye. Mean follow-up period after the operation was 2 to 16 months (average : 8.1 months).

Results

Postoperatively, the MRD 1 increased by 1.81±0.88 mm on the average, corresponding to the improvement in lid elevation after the use of 10% phenylephrine performed before resection. Surgery was successful in most patients, and postoperative difference in MRD 1 was less than 1 mm from the sound eye. No special postoperative complication was observed.

Conclusions

Conjunctiva-Müller muscle resection is one of the effective methods of correcting mild ptosis in anophthalmic patients.

Effectiveness of the gold weight trial procedure in predicting the ideal weight for lid loading in facial palsy: a prospective study

PURPOSE

To evaluate the effectiveness of the gold weight trial procedure in predicting postoperative eyelid closure after gold weight implantation surgery for facial palsy.

DESIGN

Prospective, interventional case series.

METHODS

Patients with facial palsy undergoing gold weight implantation were enrolled prospectively to undergo the standard gold weight trial procedure. The criteria for ideal gold weight were defined before surgery as a minimum 50% reduction in lagophthalmos without induction of more than 2 mm ptosis during the trial procedure. The corrected weight (ideal gold weight + 0.2 g) was implanted in the pretarsal space. The main outcome measure was reduction in lagophthalmos according to predefined criteria at six weeks after surgery.

RESULTS

Thirty eyes of 29 patients underwent gold weight implantation. The mean age at surgery was 41.6 years, and the median predicted ideal gold weight was 1.2 g. The mean preoperative lagophthalmos of 7 mm reduced to 2.3 mm at six weeks after surgery. As defined by the success criteria, undercorrection was noted in nine eyes (30%) at six weeks after surgery. A preoperative lagophthalmos of 8 mm or more was noted in seven (77.8%) of nine eyes in the undercorrection group, compared with six (28.6%) of 21 eyes in the success group. Six of the nine failures required implant exchange.

CONCLUSIONS

The ideal gold weight as estimated by the trial procedure (with 0.2 g correction factor) led to undercorrection in 30% cases. Undercorrection was common (78%) in patients with preoperative lagophthalmos of more than 8 mm.