Intraoperative Quantification Using Finger Force for Involutional Blepharoptosis without Postoperative Lagophthalmos

Tape Tarsorrhaphy in the Management of Lagophthalmos Caused by Severe Congenital Blepharoptosis Procedures

BACKGROUND

Lagophthalmos, a common complication after blepharoptosis correction, has plagued oculoplastic surgeons. The goal of this study was to investigate the effect of tape eyelid closure on reducing the occurrence of lagophthalmos after blepharoptosis correction.

METHODS

From April 2020 to June 2021, a total of 112 patients with severe congenital ptosis received corrective surgery at the Department of Plastic and Reconstructive Surgery, Xijing Hospital, Fourth Military Medical University. Of these, 48 underwent frontalis muscle advancement technique and 64 underwent conjoint fascial sheath suspension. Preoperative data collected included demographics, levator function, Bell's phenomenon, and marginal reflex distance 1 (MRD1). Postoperative data included surgery type, MRD1, eyelid closure function, aesthetic outcomes (including eyelid contour, eyelid symmetry, and eyelid crease), keratitis, and other complications.

RESULTS

Frontalis muscle advancement technique group: the median of safe eye closure time was 7.3 months (positive Bell's phenomenon; interquartile range [IQR], 3.8-10.8 months) and 13.9 months (poor Bell's phenomenon; IQR, 11.6-16.1 months). There was a significant improvement between the preoperative and postoperative MRD1 (-1.52 ± 0.82 vs 3.85 ± 0.58 mm, P < 0.05). Conjoint fascial sheath suspension group: the median of safe eye closure time was 5.7 months (positive Bell's phenomenon; IQR, 2.9-8.5 months) and 12.4 months (poor Bell's phenomenon; IQR, 8.1-16.7 months). There was a significant improvement between the preoperative and postoperative MRD1 (-1.02 ± 0.91 vs 4.15 ± 1.03 mm, P < 0.05). All patients/guardians were satisfied with the aesthetic outcomes.

CONCLUSIONS

Tape tarsorrhaphy is a safe, easy-to-learn method for treating lagophthalmos with a good aesthetic outcome.

Factors Influencing the Lagophthalmos and Lid Lag After Simple Congenital Blepharoptosis Correction

BACKGROUND

Lagophthalmos and lid lag is the most common complication after ptosis correction. Great efforts had been made to control it, but little was known about the factors influencing it. So we ran this research to explore the possible mechanisms underlying it. This would be beneficial to solving this problem.

MATERIALS AND METHODS

In this cohort study, patients treated with the forked frontalis muscle aponeurosis suspension and levator aponeurosis-Muller's muscle complex resection were identified. Lagophthalmos height and lid lag was measured at the postoperative week 1 visits. The Spearman correlation test was run to test whether lagophthalmos was related to patients' age, levator function, and severity of ptosis. Then we measured the contents of collagen and elastin fibers of frontalis muscle fascia and levator aponeurosis from the patients and levator aponeurosis from cadaver heads histologically and compared the contents in these 3 groups.

RESULTS

No correlation was found between patients' age, levator function, the severity of ptosis, and with lagophthalmos height. However, the contents of collagen and elastic fibers were both higher in the frontalis fascia than in the normal aponeurosis tissues. The difference in collagen fibers content between frontalis muscle fascia and patients' aponeurosis was statistically insignificant.

CONCLUSIONS

The severe lagophthalmos and lid lag may be caused by the poor mechanical features of the frontalis muscle. A better source of motive force to elevate the eyelids and a novel sling material with proper elasticity and stiffness would be the solution to improve the lagophthalmos and lid lag after ptosis correction.

Surgical outcomes of the anterior versus posterior approach for advancement of the levator aponeurosis in Japanese patients

PURPOSE

To compare the surgical outcomes of the anterior and posterior approaches for advancement of the levator aponeurosis for aponeurotic blepharoptosis in relation to levator function (LF).

METHODS

This retrospective study included 223 eyelids from 125 patients with aponeurotic blepharoptosis. The anterior approach was used for 115 eyelids from 65 patients (anterior group), while the posterior approach was used in 108 eyelids from 60 patients (posterior group). Patients were subdivided into two groups in accordance with their LF (fair: 5-10 mm; good: > 10 mm). Functional success was defined as a margin reflex distance of 2-5 mm without serious complications at 3 months postoperatively. Cosmetic success was defined as the achievement of ≤ 1 mm laterality of the upper eyelid height, ≤ 2 mm laterality of the pretarsal show, and eyelid contour symmetry at 3 months postoperatively.

RESULTS

The functional success rates of the anterior and posterior groups were comparable for patients with good LF (78.9% vs 87.7%, p = 0.228), whereas it was better in the posterior group (85.7%) than the anterior group (64.1%) in the total group (p = 0.022) and in patients with fair LF (p = 0.031). The posterior group achieved better cosmetic success than the anterior group regarding upper eyelid height symmetry (p = 0.042) and pretarsal show (p = 0.012). No serious complications occurred during follow-up.

CONCLUSIONS

The posterior approach achieved better functional and cosmetic outcomes than the anterior approach, indicating that the posterior approach is more useful in patients with aponeurotic blepharoptosis, particularly for those with only fair LF.

Lagophthalmos caused by cicatricial adhesion of orbital adipose tissue to orbital roof: A case report

Purpose

To report a case of lagophthalmos caused by cicatricial adhesion of orbital adipose tissue to the orbital roof.

Observations

A 23-year-old female was presented with right lagophthalmos. Five months prior to consult at our clinic, she suffered from a penetrating trauma to the frontal lobe of the brain through the right orbital roof with cerebrospinal fluid leakage. Decompressive craniectomy was performed immediately after the injury using a coronal incision, which was followed by reconstruction with an artificial bone 1 month later. On examination at our clinic, she showed right exposure keratopathy with best corrected visual acuity of 20/100 due to corneal opacity. The palpebral contracted scar was first elongated using Z-plasty technique but excursion of the upper eyelid under a finger force assistance was insufficient to eliminate lagophthalmos. However, complete eyelid closure under a finger force assistance was achieved after sharp dissection of the cicatrized adipose tissue from the orbital roof. An autogenous dermis-fat was grafted on the orbital roof and superior orbital rim to avoid adhesion of orbital adipose tissue onto the bone again.

Conclusion and importance

Cicatricial adhesion of an orbital adipose tissue to the orbital roof is one of the possible causes of posttraumatic lagophthalmos in patients with an orbital roof fracture. Surgeons need to be aware of this condition in planning of surgical repair when such a fracture is encountered.

What Is the Best Way to Handle the Involutional Blepharoptosis Repair?

There are many different operations to correct involutional blepharoptosis (IB); however, the outcome of the corrective surgery is rather unpredictable, regardless of the procedure employed. A reasonably predictable outcome can be achieved with careful intraoperative evaluation of the condition, with measuring of the margin reflex distance-1 (MRD-1) in supine position of the patients. With these prepositions, we collected data that indicated that our approach can achieve a predictable outcome. This was a prospective study of 21 consecutive patients (8 men and 13 women) involving 42 eyelids with IB. IB was defined as an MRD-1 of <2  mm. All 21 patients were informed of the purposes of the study, and underwent levator aponeurosis advancement. The MRD-1 was measured intraoperatively with the patients in a supine position and in the 3-month postoperative inspection with the patients in a sitting position. Statistical analyses using paired t-tests were performed. From intraoperative measurement, mean MRD-1 values were 4.31  mm on the right side (range 3.0-4.5) and 4.29  mm on the left side (range 3.5-5.0). Three months after the operations, mean MRD-1 values were 3.07  mm on the right side (range 1.5-4.0) and 3.07  mm on the left side (range 2.0-4.0). Compared with the intraoperative MRD-1 measurements, those of the postoperatives were significantly 1.2  mm reduced (right: P < 0.01, left: P < 0.01). The intraoperative measurement of MRD-1 without changing position of patients could result in successful outcome of the operation.

Levator aponeurosis sandwich flap for reconstruction of upper eyelid defect

A 72-year-old woman suffered from a sebaceous gland carcinoma on her left upper eyelid. The tumour was 13 × 5 mm without metastasis. The tumour was excised with a 5-mm safety margin, resulting in a large, full-thickness defect in which almost all of the tarsal plate, approximately half of the orbicularis oculi muscle, and part of the levator aponeurosis were lost. Reconstruction of the upper eyelid was successfully performed with a levator aponeurosis sandwich flap, upon which the posterior lamella was covered by a free tarsal graft with medial and lateral periosteal flaps, and a skin graft from the contralateral upper eyelid for the anterior lamella. No lagophthalmos was demonstrated after the operation. Six months postoperatively, there was no tumour recurrence, no ocular complications, and good cosmetic results.

Inferior displacement of the lower eyelid during intraoperative quantification in blepharoptosis surgery

Purpose:

To examine inferior displacement of the lower eyelid during eye closing in intraoperative quantification of blepharoptosis surgery.

Methods:

A series of lower eyelid movements during eye closing in intraoperative quantification of blepharoptosis surgery were examined in 30 eyelids of 15 patients (6 males and 9 females; mean age 70.0 years; range 43–81 years) with bilateral aponeurotic blepharoptosis.

Results:

Inferior displacement of the lower eyelid was observed in all eyelids examined, although the extent varied in each patient (range 2.0–4.5 mm; mean 3.2 mm). Inferior displacement occurred with upward eye movement caused by Bell’s phenomenon. Many wrinkles were simultaneously observed as a result of contraction of the orbicularis oculi muscle. After maintaining the inferiorly displaced state for several seconds, 20 lower eyelids in 10 patients naturally moved superiorly to a resting position. On the other hand, 10 lower eyelids in 5 patients remained in the same inferior position for more than 5 seconds, after which we had to manually elevate them to a resting position. The eyes then moved inferiorly to their resting position with a decrease in the number of lower eyelid wrinkles. Once the patients opened their eyes, inferior displacement of the lower eyelid completely disappeared.

Conclusions:

Inferior displacement of the lower eyelid during eye closing increases the amount of lagophthalmos. This phenomenon needs to be considered for quantifying the intraoperative lagophthalmos level during blepharoptosis surgery.

Transcutaneous Blepharoptosis Surgery: Simultaneous Advancement of the Levator Aponeurosis and Müller's Muscle (Levator Resection)

Transcutaneous blepharoptosis surgery with simultaneous advancement of the levator aponeurosis and Müller’s muscle (levator resection) is a popular surgery which is considered effective for all types of blepharoptosis except for the myogenic type. Repair of ptosis cases with good levator function yields excellent results. A good outcome can be also obtained in cases with poor levator function, however, in such cases; a large degree of levator advancement may be required, which may result in postoperative dry eyes, unnatural eyelid curvature and astigmatism. These cases are therefore better treated with sling surgery. With the right patient selection, the levator resection technique is an effective method for ptosis repair.

Assessment of the Predictive Value of Intraoperative Eyelid Height Measurements in Sitting and Supine Positions During Blepharoptosis Repair

PURPOSE

To examine relationships between intraoperative and postoperative eyelid heights in relation to patient postures in blepharoptosis surgery.

METHODS

Thirty eyelids in 15 patients with bilateral aponeurotic ptosis were selected. The margin reflex distance-1 (MRD-1) was measured with the patients in the sitting position preoperatively, intraoperatively, and in the postoperative 6 weeks. MRD-1 also was measured intraoperatively with patients in the supine position. The intraoperative sitting and supine values and the postoperative values were statistically compared using a paired t test, and lateralities in those groups were statistically analyzed using Student's t test.

RESULTS

From the intraoperative measurements, mean MRD-1 values in the sitting position (right: 3.80 mm, left: 3.73 mm) were significantly lower than those in the supine position (right: 4.37 mm, p < 0.001; left: 4.33 mm, p < 0.001). In the postoperative 6 weeks, mean MRD-1 values (right: 3.80 mm, left: 3.63 mm) were not significantly different from intraoperative values in the sitting position (right: p = 1.000, left: p = 0.189), but were significantly lower than intraoperative values in the supine position (right: p < 0.001, left: p < 0.001). There was no significant laterality among the three groups (supine intraoperative: p = 0.890, sitting intraoperative: p = 0.785, postoperative: p = 0.546).

CONCLUSION

Intraoperative measurements in the sitting position more accurately predicted postoperative eyelid height than did measurements with the patient in a supine position.