Incidence and risk of ptosis following ocular surgery: a systematic review and meta-analysis

Progressively worsening ptosis in a woman: A case report

Key Clinical Message

Filler injections into the upper eyelid may cause levator aponeurosis fibrosis and ptosis. This risk must be considered. When ptosis appears, treatment might be difficult. Understanding the upper eyelid anatomy and procedures is essential to prevent eyelid damage.

Abstract

Ptosis is a prevalent condition in cosmetic surgery that occurs due to malfunction of the levator palpebrae superioris or insufficient Müller muscle action. It is characterized by the upper eyelid edge appearing lower than usual when seen at eye level. Ptosis may be categorized into congenital and acquired forms. The primary cause of congenital ptosis is attributed to abnormalities of the levator palpebrae superioris muscle or the motor nerve innervation that controls it. The condition arises from atypical development and malfunction of the oculomotor system. Acquired ptosis may be classified into many categories including traumatic, neurogenic, myogenic, senile, mechanical, and fake ptosis. Currently, there is little documentation of ptosis resulting from the degeneration of the aponeurosis of the muscle in the upper eyelid. We received a case of ptosis caused by fibrosis of the levator palpebrae superioris aponeurotic membrane. We used the technique of levator palpebrae superioris great advancement. The levator palpebrae superioris-Müller muscle was folded to create a stable composite construction via the levator palpebrae superioris high progress.

Topical Review: An Update of Diagnostic and Management Algorithms for Acquired Blepharoptosis

SIGNIFICANCE

Acquired ptosis is a condition of the upper eyelid that has negative cosmetic and functional effects but is likely underdiagnosed and undertreated. Given the evolving understanding of the condition and expanding therapeutic options, this review reappraised published evidence and clinical experience regarding diagnosis and treatment of acquired ptosis.The authors met over two structured virtual working sessions to review current evidence and develop timely recommendations for acquired ptosis identification, differential diagnosis, characterization, and treatment selection. Diagnostic algorithms, plus management and referral guidelines, are presented. Eyelid evaluation and, when needed, ptosis diagnostic workup are essential in the comprehensive eye examination. Acquired ptosis can be efficiently identified via patient questionnaire, history, and photograph review combined with assessment of eyelid position and symmetry using established methods. When ptosis is present, it is essential to evaluate onset, symptoms, pupil diameter, and extraocular muscle function to identify or rule out serious underlying conditions. If signs of serious underlying etiology are present, immediate referral/follow-up testing is required. After ruling out serious underlying causes, masquerade conditions, and pseudoptosis, pharmacologic or surgical treatment should be selected based on the clinical evidence. Effectively managing acquired ptosis requires practice-wide commitment to thorough eyelid evaluation, accurate diagnosis, and adoption of new treatment modalities. Aided by evolving pharmacologic therapeutic options, shifting from a "detect and refer" to a "diagnose and manage" approach can support identification and treatment of more patients with acquired ptosis, particularly mild-to-moderate cases.

Lower eyelid involutional entropion following cataract surgery

OBJECTIVES

To determine whether cataract surgery is associated with an increased risk of subsequent lower eyelid entropion and evaluate potential associated factors.

METHODS

This retrospective cohort study included consecutive patients undergoing first eye cataract surgery over a 10-year period at a single institution (n = 14,574). The fellow phakic eye served as control. Patient records were evaluated up until either the time of second eye cataract surgery or any other intraocular or adnexal surgery. The primary outcome was the rate of entropion repair in both the pseudophakic (exposed) group and the phakic control group. Groups were compared using relative risk and Kaplan-Meier analysis. Multivariate logistic regression was used to compare pre-specified characteristics of those patients that underwent entropion repair in their pseudophakic eye with those that did not.

RESULTS

A fourfold higher relative risk of undergoing entropion repair was observed in eyes that had undergone cataract surgery compared with the fellow unoperated eye (95% confidence interval 1.6-9.8; P < 0.001) with an increased risk at all timepoints between 1 and 12 years according to Kaplan-Meier analysis (P = 0.001). Median time to entropion repair after cataract surgery was 58 months (range 3-124). Documented intraoperative patient factors such as patient or eye movement, eyelid squeezing, pain or anxiety were an independent risk factor for subsequent entropion (P < 0.0001).

CONCLUSIONS

Cataract surgery is associated with an increased risk of subsequent lower eyelid entropion. Surgeons should be aware of this risk in the pre- and post-operative assessment of patients undergoing cataract surgery.

Association of Oxymetazoline Hydrochloride, 0.1%, Solution Administration With Visual Field in Acquired Ptosis: A Pooled Analysis of 2 Randomized Clinical Trials

Importance

Treatment of acquired blepharoptosis (ptosis) is currently limited to surgical intervention.

Objective

To examine the efficacy and safety of oxymetazoline hydrochloride, 0.1%, ophthalmic solution (oxymetazoline, 0.1%) in participants with acquired ptosis.

Design, Setting, and Participants

This pooled analysis of 2 randomized, double-masked, placebo-controlled, multicenter phase 3 clinical trials included participants 9 years and older with acquired ptosis and superior visual field deficit. The 2 studies were conducted across 16 and 27 sites in the United States. Patients were enrolled from May 2015 to April 2019. Analyses for the individual trials were initiated after database lock and completed on September 6, 2017, and May 16, 2019. Pooled analysis was completed on August 25, 2019.

Interventions

Participants (randomized 2:1) received oxymetazoline, 0.1%, or vehicle, self-administered as a single drop per eye, once daily, for 42 days.

Main Outcomes and Measures

The primary efficacy end point was change from baseline in the number of points seen on the Leicester Peripheral Field Test, a test to detect superior visual field deficits due to ptosis, on days 1 (6 hours after instillation) and 14 (2 hours after instillation). The secondary end point, change from baseline in marginal reflex distance 1, was assessed at the same time points.

Results

In total, 304 participants were enrolled (mean [SD] age, 63.8 [13.8] years; 222 women [73%]). Overall, 97.5% (198 of 203) of participants receiving oxymetazoline, 0.1%, and 97.0% (98 of 101) of participants receiving vehicle completed the studies. Oxymetazoline, 0.1%, was associated with a significant increase in the mean (SD) number of points seen on the Leicester Peripheral Field Test vs vehicle (day 1: 5.9 [6.4] vs 1.8 [4.1]; mean difference, 4.07 [95% CI, 2.74-5.39]; P < .001; day 14: 7.1 [5.9] vs 2.4 [5.5]; mean difference, 4.74 [95% CI, 3.43-6.04]; P < .001). Oxymetazoline, 0.1%, also was associated with a significant increase in marginal reflex distance 1 from baseline (mean [SD]: day 1: 0.96 [0.89] mm vs 0.50 [0.81] mm; mean difference, 0.47 mm [95% CI, 0.27-0.67]; P < .001; day 14: 1.16 [0.87] mm vs 0.50 [0.80] mm; mean difference, 0.67 mm [95% CI, 0.46-0.88]; P < .001). Treatment-emergent adverse events (TEAEs) occurred in 31.0% (63 of 203) of participants receiving oxymetazoline, 0.1%, and 35.6% (36 of 101) of participants receiving vehicle. Among participants receiving oxymetazoline, 0.1%, with a TEAE, 81% (51 of 63) had a maximum TEAE intensity of mild, and 62% (39 of 63) had no TEAE suspected of being treatment related.

Conclusions and Relevance

Oxymetazoline, 0.1%, was associated with positive outcomes and was well tolerated in phase 3 trials after instillation at days 1 and 14, demonstrating its potential promise for the treatment of acquired ptosis, although further study is needed to elucidate the clinical relevance of these findings beyond 6 weeks.

Does cataract surgery in patients with concurrent lower lid malposition increase the risk of postoperative endophthalmitis?

OBJECTIVE

To evaluate the safety of performing cataract surgery prior to eyelid (entropion/ectropion) surgery in patients with concurrent cataract and lower eyelid malposition.

DESIGN

Retrospective case series.

PARTICIPANTS AND METHODS

Patients with concurrent lower eyelid malposition and cataract undergoing cataract surgery before lower eyelid repair from 2013 to 2020 were identified from two ophthalmologists (M.L.W., G.R.). Both surgeries were performed by the same ophthalmologist, with eyelid repair completed at least 1 month following cataract extraction. Data analysis was performed with two-parameter estimations. The primary outcome was the postoperative endophthalmitis rate in this cohort.

RESULTS

129 cases in 90 patients were found (86 involutional entropion and 43 involutional ectropion). No cases of endophthalmitis were encountered. Statistical analysis using the 95% Jeffreys interval for one-sample binomial proportion revealed an upper limit of 1.9%. The Agresti-Caffo interval of the proportional difference between the study procedure and historical incidence data of postoperative endophthalmitis following cataract surgery alone yielded an estimate of 0.8% with an upper confidence limit of 2.2%.

CONCLUSION

We present preliminary evidence on the endophthalmitis risk in patients with concurrent lower eyelid malposition and cataract who undergo cataract surgery prior to eyelid repair. We propose that this strategy may be a viable option to expedite vision restoration and reduce the risk of recurrent lower eyelid malposition in select patients. More data are required to reach statistically significant noninferiority and show that a malpositioned lower eyelid is not a risk factor for postoperative endophthalmitis following cataract surgery.

A review of acquired blepharoptosis: prevalence, diagnosis, and current treatment options

Blepharoptosis (ptosis) is among the most common disorders of the upper eyelid encountered in both optometric and ophthalmic practice. The unilateral or bilateral drooping of the upper eyelid that characterises ptosis can affect appearance and impair visual function, both of which can negatively impact quality of life. While there are several known forms of congenital ptosis, acquired ptosis (appearing later in life, due to a variety of causes) is the predominant form of the condition. This review summarises the prevalence, causes, identification, differential diagnosis, and treatment of acquired ptosis. Particular attention is paid to the differential diagnosis of acquired ptosis and emerging treatment options, including surgical and pharmacologic approaches.

Ophthalmic Surgeries and Systemic Medical Conditions Associated With the Development of Involutional Ptosis

PURPOSE

To investigate the associations between systemic medical conditions and types of ocular surgery and the development of aponeurotic ptosis.

METHODS

In this case-control observational cohort study, the relative prevalence of involutional ptosis in a large population of adult patients was assessed. Deidentified patient data from a 10-year time period was obtained from the electronic medical records of 5 large academic medical centers. Patients were selected based on ICD9 and ICD10 codes for involutional ptosis. Control patients were age and gender matched and randomly selected from a general adult population. Systemic comorbidities were determined based on ICD9 and ICD10 codes, and prior ocular surgeries based on CPT codes. The influence of systemic comorbidities and ocular surgery was examined utilizing logistic regression analysis.

RESULTS

The study cohort consisted of 8297 adult patients with involutional blepharoptosis and 13,128 matched controls. The average age was 65 years. The 3 significant risk factors for developing ptosis were ocular surgery, hyperthyroidism, and type II diabetes with odds ratios of 4.2, 2.5, and 1.45, respectively (p < 0.05). Strabismus, cornea, and glaucoma surgeries were more highly associated with developing ptosis (p < 0.05). Strabismus surgery had the greatest odds ratio of 3.37, followed by cornea surgery at 2.31, and glaucoma surgery at 1.56.

CONCLUSIONS

Involutional ptosis is likely a multifactorial process. This study demonstrates that risk factors for the development of ptosis include ocular surgery, specifically strabismus, cornea, and glaucoma surgery, as well as hyperthyroidism and type II diabetes.

Müller Muscle-conjunctival Resection with or without Tarsectomy and Combined with Bandage Contact Lens Use in Ptosis Patients with Corneal Graft

PURPOSE

To examine the efficacy of ptosis correction with a Müller muscle-conjunctival resection with or without tarsectomy (MMCR±T), combined with bandage contact lens (BCL) use, in corneal graft patients.

METHODS

Seven patients with corneal grafts who underwent MMCR±T for treatment of ptosis were evaluated retrospectively. A BCL was applied to the grafts at the end of the surgery. The collected data included preoperative and postoperative visual acuity, marginal reflex distance 1 (MRD-1), presence of Hering's dependency by the phenylephrine test, symmetry outcomes, and complications after MMCR±T.

RESULTS

The average duration between the penetrating keratoplasty and MMCR±T was 14 months, with a follow-up time of 10.4 months after MMCR±T. Hering's dependency was observed in four (57.2%) patients before MMCR±T, and MRD-1 was increased in all patients based on preoperative phenylephrine tests. The mean preoperative MRD-1 was -0.14 ± 0.55 mm, and the mean postoperative MRD-1 was 2.35 ± 0.89 mm (p < 0.0001). Symmetry outcomes of perfect (<0.5 mm), good (0.5-1 mm), and fair (≥1 mm) were noted after MMCR±T in three, three, and one patients, respectively. During the follow-up, no obvious corneal epitheliopathy, keratitis, or corneal graft rejection/failure were noted in any cases. BCL use was well tolerated by all patients.

CONCLUSIONS

Most patients achieved good surgical outcomes with the application of the BCL to protect the graft and with the use of the phenylephrine test and Hering's dependency to predict the final eyelid position and symmetry. MMCR±T combined with BCL may therefore represent an alternative approach for correction of ptosis in patients with corneal graft.

Postoperative blepharoptosis after trabeculectomy versus ahmed glaucoma valve implantation

Purpose:

To investigate the frequency of persistent postoperative ptosis (PP) following trabeculectomy or Ahmed glaucoma valve (AGV) implantation and to analyze the associated factors.

Methods:

It is a prospective observational study on glaucoma patients who underwent trabeculectomy or AGV implantation from October 2015 to June 2017 in a tertiary center. Margin reflex distance 1 and 2 (MRD1 and 2) and levator function were measured before and at least 6 months, postoperatively. Clinically significant ptosis was defined as ≥2 mm drop of MRD1.

Results:

One hundred and fourteen patients (124 eyelids) including 76 patients (87 eyelids) with trabeculectomy and 35 patients (37 eyelids) with AGV implantation were included. The mean age was 55.50 (standard deviation = 17.54) years. Most of the surgeries were performed under general anesthesia (87.9%, 109/124) between 30 and 60 min (53.2%, 66/124) by residents (39.5%, 49/124). Trabeculectomy and AGV groups did not differ in terms of pre, intra, and postoperative variables (0.1≤ P ≤0.9) except duration of surgery (P = 0.01) and sex (P = 0.04). Clinically significant persistent PP was observed in 12.9% (16/124) in total, 13.7% (12/87) in the trabeculectomy group, and 10.8% (4/37) in the AGV group (P = 0.6). Male gender (ß coefficient = 2.56, 95% confidence interval (CI) = 4.76–0.36, P = 0.02) and a higher preoperative MRD1 (ß coefficient = 1.24, 95% CI = 0.52–1.95, P = 0.001) were the only factors affecting the frequency of clinically significant PP.

Conclusions:

Postoperative blepharoptosis occurred in 12.9% of eyes after glaucoma procedures. Male gender and higher preoperative MRD1 were significantly associated with a higher frequency of postglaucoma surgery blepharoptosis.

Postoperative Blepharoptosis After Pars Plana Vitrectomy Procedure

PURPOSE

To describe the frequency of blepharoptosis and factors affecting it after the pars plana vitrectomy (PPV) procedure.

METHODS

In a prospective study, patients were recruited consecutively from October 2016 to June 2018. Upper eyelid margin reflex distance 1 and 2 (MRD1 and 2), upper eyelid crease height, and levator function were measured before, 1 and at least 6 months after surgery by the same investigator. Clinical and Clinically significant ptosis were defined as ≥0.5 and ≥2 mm drop of MRD1.

RESULT

There were 60 eyes from 57 patients. The majority of surgeries were performed by the fellows (63.3%, 38/60) and under general anesthesia (95.0%, 57/60). Clinical and clinically significant ptosis following PPV were 47.2% (25/53) and 11.3% (6/53) at the last follow up (at least 6 months), respectively. MRD2 (p = 0.389) and eyelid crease height (p = 0.057) did not significantly change. Surgeons' level, time of the procedure and other variables were not significantly impacting the frequencies.

CONCLUSION

Persistent clinically significant ptosis was observed in 11% of patients undergoing PPV. No variable was significantly associated with persistent postoperative ptosis after PPV.