Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material

Outcomes for expanded polytetrafluoroethylene strip in frontalis suspension surgery

PURPOSE

This study evaluates surgical outcomes and complication rates of frontalis suspension with expanded polytetrafluoroethylene (ePTFE).

METHODS

This retrospective cohort study reviewed all patients undergoing frontalis suspension surgery using ePTFE as the sling material from January 1 2012 to March 3 2020 by a single surgeon at a single academic center. Two different surgical techniques were evaluated in the placement of the sling material. Demographic, clinical, and operative data were extracted. Outcome data including postoperative lid height, reoperation, and complication rate were extracted for the cohort and compared between the two surgical techniques. Descriptive statistics were utilized.

RESULTS

Sixty-four eyes from 49 unique patients were included in this study. Forty-three (67.2%) patients had isolated congenital blepharoptosis; 14 (21.9%) had blepharophimosis, ptosis, and epicanthus inversus syndrome (BPES); and 2 (3.1%) had cranial nerve III palsy. Fifty-one (79.7%) patients had no prior blepharoptosis surgery. Lid crease incision and stab incision techniques were utilized for 24 (37.5%) and 40 (62.5%) eyes, respectively. Overall, 21 (32.8%) eyes required reoperation with ePTFE to achieve appropriate eyelid height or contour. Only one patient experienced implant infection, requiring removal of ePTFE sling after a second reoperation. There were no cases of implant exposure or granuloma formation noted during the study period.

CONCLUSION

An ePTFE strip soaked in cefazolin prior to utilization in surgery is a viable material for frontalis suspension surgery, with a lower infectious or inflammatory complication rate than previously reported. However, reoperation rate was still relatively high.

Delayed infections following polybutylate-coated polyester (Ethibond) suture frontalis suspension surgery for severe blepharoptosis

PURPOSE

To describe the incidence and management of delayed infections following frontalis sling suspension with polybutylate-coated polyester suture (Ethibond).

METHODS

Retrospective, interventional case series of 177 eyes of 150 patients, who underwent frontalis suspension surgery with Ethibond (Johnson and Johnson, USA), at L V Prasad Eye Institute, Hyderabad, India, between January 2016 and February 2022. Patients were assessed for chronic secondary sling infection, defined as infection/suture granuloma occurring beyond 6 weeks post-surgery. All patients received postoperative oral antibiotics. The clinical profile, microbiological evaluation, antibiotic sensitivity patterns, and management outcomes were analyzed.

RESULTS

Delayed infection following Ethibond sling suspension was noted in 14 eyes of 13 patients (7.9%). Of these, eight cases (61.5%) were females. The average time interval from surgery to presentation was 7.5 months (range: 2.5 months to 2.5 years). Eleven eyes underwent sling removal. Of the three who received initial antibiotic course, two eventually needed sling removal. Microbiological evaluation was available in seven eyes (50%), with Staphylococcus aureus as the most common organism. Of the six positive cultures, five (83.3%) were resistant to fluoroquinolones (FQs).

CONCLUSION

Frontalis suspension with Ethibond has an 8% incidence of delayed infections, with Staphylococcus aureus as the most common organism. The authors recommend early sling removal in all patients with infection and recommend consideration of an alternative material in the event of future revision surgery.

Sling for the sling: a new technique for long-term correction of severe congenital ptosis

INTRODUCTION

Severe congenital ptosis poses a complex challenge for oculoplastic surgeons, requiring meticulous surgical intervention to restore eyelid function and improve aesthetic outcomes mainly by using frontalis sling approach. A crucial issue in frontalis sling surgeries is the sustainability of effect.

PURPOSE

This retrospective study reports the outcomes of two surgical techniques for treating severe congenital ptosis in the paediatric age group: Silicon rods ptosis sling and a novel technique involving the use of Silicon rods with green braided polyester (Ethibond) sutures to secure the rods in place "sling for the sling".

METHODS

The medical records of children who underwent frontalis suspension were reviewed in a retrospective fashion. We identified two groups; the first group (20 patients: 35 eyelids) had the traditional frontalis suspension surgery using silicone suspension set, the second group (14 patients: 25 eyelids) was operated using the new "sling for sling" technique. We used the postoperative marginal reflex distance-1 (MRD-1) as the primary outcome measure while the frequency of both wound related complications and recurrence were considered as secondary outcome measures. Post operative data were collected and compared after 1 month, 6 months, 12 months, and 18 months.

RESULTS

Preliminary results indicate promising outcomes for both techniques, with significant improvement in eyelid elevation observed in both groups. However, the novel technique using Silicon rods with Ethibond sutures demonstrated enhanced sustainability, leading to a more durable outcome with significantly less recurrence.

CONCLUSION

This study highlights the potential benefits of the novel technique in treating severe congenital ptosis and introduces an innovative approach to Silicone rods fixation to achieve a long-term corrective effect.

Surgical management of oculomotor nerve palsy - a review of the literature

We aim to review the surgical management techniques available for patients with oculomotor nerve (OMN) palsy, compare and contrast the approaches and subsequent outcomes. A search of the literature was carried out to yield all papers relevant to the topic, and a wide spectrum of surgical techniques were identified. These included: muscle shortening and lengthening procedures, muscle transposition, globe fixation and ptosis surgery. Patients often require a synergistic combination of these techniques. Strabismus surgery for OMN palsy can be approached through a variety of different techniques to improve the quality of life, independence and aesthetics for the patient.

Comparison of Stab Incision and Eyelid Crease Incision Techniques in Children with Revision Frontalis Sling Surgeries Using Silicone Rods

PURPOSE

To compare stab and eyelid crease incision techniques in revision frontalis sling surgeries using silicone rods.

METHODS

This retrospective study involved 52 eyes in 48 consecutive pediatric patients who underwent revision frontalis sling surgery between 2008 and 2019. All primary surgeries were performed by making eyelid crease incisions and suturing of silicone rods onto the tarsal plates. The revision surgeries were performed by either making stab incisions over the eyelid through which to pass the silicone rods (group A), or by refixing the same or a new silicone rod to the tarsal plate (group B). The surgical results were compared.

RESULTS

The mean follow-up period was 22.4 months (range, 6-62 months) and the mean age of the patients was 6.1 years (range, 1-16 years). There were 28 female and 20 male patients. Surgical success was achieved in 23 of 28 patients (82.1%) in group A, and 12 of 24 patients (50.0%) in group B. The difference between the groups was statistically significant (p = 0.012). Superficial punctate epithelial defects were detected in six group A patients (21.4%) and seven group B patients (29.1%). In group B, lid hematoma occurred in three patients (12.5%) and entropion occurred in three patients (12.5%). The silicone rods were removed from two eyes, and entropion spontaneously resolved in one eye with close follow-up.

CONCLUSIONS

Using the stab incision technique increases revision frontalis sling surgery success rates when primary surgeries are performed using eyelid crease incisions and suturing silicone rods to the tarsal plates in children.

Surgical Outcomes After Frontalis Suspension Using Expanded Polytetrafluoroethylene Sling for Congenital Ptosis

Purpose The purpose of the study is to assess short- and long-term functional outcomes after frontalis suspension using expanded polytetrafluoroethylene (ePTFE) sling for congenital ptosis repair. Methods A retrospective, observational case review was conducted on pediatric patients who underwent frontalis suspension using ePTFE sling from 2008 to 2020. Functional success was assessed by lid height, lid symmetry, and parental satisfaction with the cosmetic outcome. Clinical course and long-term functional outcomes after surgery were assessed. Results Twenty-one cases met the inclusion criteria and were assessed. The follow-up time ranged from 13 months to 11 years (mean: six years). Functional success after one surgery was 62% at early and late postoperative periods. Six of 21 cases (29%) required revisional surgery in the early postoperative period due to undercorrection. Three cases (14%) were complicated by infection and/or granuloma formation. There were no cases of ptosis recurrence in the long term if success was seen in the early postoperative period. Conclusion ePTFE slings remain an excellent option for severe congenital ptosis repair with frontalis sling, demonstrating long-term functional success, with satisfactory lid symmetry and acceptable cosmetic outcome. This is of important consideration in patients younger than three years of age, where autogenous materials may not be recommended. The need for early revisional surgery for undercorrection is not uncommon. The current authors also demonstrate a low but considerable risk for infection and/or granuloma formation.

Temporal-fasciae-complex sheet suspension for correction of severe recurrent blepharoptosis

BACKGROUND

Multiple surgical methods were performed to correct the blepharoptosis. However, the recurrence of blepharoptosis is not uncommon in clinical practice. The Temporal-Fasciae-Complex Sheet (TFC sheet) was an ideal autologous material in correcting the severe blepharoptosis. In the present retrospected study, we introduced our experience in the correction of severe recurrent blepharoptosis with the technique of TFC sheet suspension, and describe the follow-up results to illustrate its effectiveness and practicality.

METHODS

A total of 16 patients (23 eyes) with severe recurrent blepharoptosis were enrolled in this study. All the patients were performed with temporal-fasciae-complex sheet suspension surgeries for revision> 12 months after the primary surgeries by the same treatment group. The margin-to-reflex distance 1 (MRD1), correction effect, and eyelid symmetry were used to evaluate clinical outcomes.

RESULTS

19 eyelids (82.6%) showed good correction results, and 5 eyelids (21.7%) showed fair correction results. The average value of preoperative-MRD1(pre-MRD1) was - 0.17 ± 0.97, and the average value of postoperative-MRD1(post-MRD1) was 4.01 ± 1.24. There was a statistically significant difference between pre-MRD1 and post-MRD1 (p < 0.0001). Good symmetry was observed in 13 patients (81.3%). All patients enrolled were satisfied with the surgical results.

CONCLUSION

The Temporal-Fasciae-Complex Sheet Suspension is an effective and safe method for correcting the recurrent blepharoptosis.

Congenital ptosis repair in children: comparison of frontalis muscle suspension surgery and levator muscle surgery

PURPOSE

Comparing the surgical and refractive outcomes of congenital ptosis repair by different surgical techniques.

METHODS

This longitudinal cohort study reviewed medical records of 101 patients who underwent congenital ptosis repair, from 2006 to 2022 in a single center. Analysis was performed for demographic background, co-morbidities, pre-operative and post-operative ocular examinations and refraction, complications, reoperations, and success rates.

RESULTS

Following exclusion criteria, we remained with 80 patients (103 eyes) who underwent either frontalis muscle suspension surgery (FMS) (55 eyes) or levator muscle surgery (LM) (48 eyes). Patients in the FMS group were younger (mean age of 3.1 vs. 6.0 years, p < 0.001) and had worse pre-operative ocular assessments including prevalence of visual axis involvement, chin-up head position, ptosis severity, and levator muscle function (LF) (p < 0.001). Both groups had a 25% rate of reoperation, however while in the LM group reoperation was required solely due to undercorrection, in the FMS group various indications prompted reoperation. Success rate was higher in the FMS group (87.3% vs. 60.4%, p = 0.002). While pre-operative astigmatism was higher in the LM group (p = 0.019), no significant differences were observed post-operatively. Spherical and spherical equivalent changes over time were significant only in the FMS group (p = 0.010 and p = 0.004, respectively).

CONCLUSIONS

Within our cohort, a higher success rate of congenital ptosis repair was observed among patients who underwent FMS compared to LM, despite similar reoperation rates. In cases of severe ptosis and moderate LF, LM demonstrated a lower-than-anticipated success rate. Astigmatic changes following ptosis repair were not consistent in either group.

Predictability of the Phenylephrine Test in Congenital Ptosis: Ten Years of Experience

PURPOSE

To assess the predictability of phenylephrine testing for congenital ptosis and review outcomes of Müller's Muscle-conjunctival resection (MMCR) for congenital ptosis across ten years of follow-up.

METHODS

In this retrospective case series, all patients who underwent MMCR for congenital ptosis at a single institution between 2010 and 2020 were identified. Exclusion criteria included patients who had not undergone preoperative testing with 2.5% phenylephrine in the superior fornix; patients who underwent revision surgery; and patients who had a broken suture in the early postoperative period. Demographics, margin-reflex distance 1 (MRD1) values pre- and postphenylephrine, millimeters of tissue resected intraoperatively, and final postoperative MRD1 were recorded.

RESULTS

A total of 28 patients were included; 19 patients received MMCR and 9 patients received a combined MMCR plus tarsectomy. The amount of tissue resected ranged from 5 to 11 mm. There was no significant difference between median postphenylephrine MRD1 and median final postoperative MRD1 in either surgical group. Neither patient age nor levator function was significantly associated with a change in MRD1 in either group. The addition of a tarsectomy had no bearing on the final MRD1 value.

CONCLUSIONS

MMCR is a viable option for patients with congenital ptosis and moderate levator function with a response to phenylephrine. In these patients, MRD1 after 2.5% phenylephrine testing correlates to the final postoperative MRD1 outcome within 0.5 mm.

The Recurrence of Ptosis after Correction Surgery Is Associated with Refractive Error

Background and objectives: Previous studies on ptosis recurrence after correction surgery have tended to focus on postoperative complications, surgical methods and suspension materials, few have mentioned refractive error. This research is to investigate the potential relation between refractive error and recurrence after correction surgery in pediatric patients with simple congenital ptosis. Materials and Methods: We conducted a retrospective analysis of data from patients with simple congenital ptosis who were treated at Zhongshan Ophthalmic Center (ZOC) between 2017 and 2020. In total, 111 eyelids of 85 patients without surgery-related complications who underwent frontalis muscle flap suspension (FMFS) for simple congenital ptosis were included. Postoperative changes in eyelid height were assessed. Cycloplegic refraction was assessed before surgery and during the follow-up period (every 3 months after surgery). Recurrence in the postoperative period was defined as a marginal reflex distance 1 (MRD1) of <1 mm. Results: There were 16 recurrence and 69 non-recurrence cases, with no statistically significant differences, in terms of patient age at the time of surgery, patient sex, or preoperative MRD1, between the recurrence and non-recurrence groups. The postoperative cylindrical diopter (adjusted odds ratio [OR] = 0.432, p = 0.005), laterality (adjusted OR = 0.202, p = 0.006), and preoperative MRD1 (adjusted OR = 0.617, p = 0.019) were associated with ptosis recurrence after surgery. Differences between the recurrence and non-recurrence groups in spherical diopter and spherical equivalent (SE) before and after surgery were not statistically significant. In addition, preoperative refractive error and postoperative spherical diopter were not significantly associated with ptosis recurrence after correction surgery. Conclusions: Ptosis recurrence after FMFS in pediatric cases of congenital ptosis is associated with refractive error. Timely refractive correction and amblyopia treatment may help to reduce ptosis recurrence.

Amblyopic astigmatism characteristics and surgical outcomes in younger children with severe congenital ptosis after frontalis suspension surgery

BACKGROUND

To examine the astigmatism characteristics and surgical outcomes in patients with unilateral severe congenital ptosis following frontalis suspension surgery.

METHODS

We included 53 congenital ptosis patients who underwent frontalis suspension surgery in Hunan Children's Hospital. Each patient underwent a refractive examination before and after surgery to assess astigmatism. We also evaluated the effects and complications associated with the procedure.

RESULTS

Degree of astigmatism in ptotic and fellow eyes was - 1.45 ± 0.59 D and - 0.66 ± 0.51 D before surgery. Ratio of severe astigmatism in ptotic and fellow eyes was 51.3 and 12.8%. The fellow eyes presented with with-the-rule astigmatism (WR; 71.8%) and against-the-rule astigmatism (AR; 20.5%) types, with no cases of oblique astigmatism (OA). Ptotic eyes demonstrated higher frequencies of AR (59.0%) and OA (10.2%) than did fellow eyes. Furthermore, the former showed increased astigmatism, followed by a gradual decrease at the 6-month, before significantly decreasing at the 1-year postoperatively. The ratio of postoperative AR and OA astigmatism cases in ptotic eyes decreased to 35.9 and 7.7% 1 month postoperatively. However, there was a postoperative increase in the WR ratio from 30.8 to 56.4% after 1 month. Kaplan-Meier survival analysis showed a success rate of 81.4% at 6 months and 62.9% at 12 months which was influenced by the following complications: suture reaction, epithelial keratopathy, infection and granuloma, lid lag, and recurrence.

CONCLUSION

Monocular congenital ptosis could develop severe astigmatism and higher frequency of AR or OA, early surgery may ameliorate astigmatic amblyopia.

Survey of ptosis practice patterns among surgeons in Asia Pacific Society of Ophthalmic Plastic and Reconstructive Surgery (APSOPRS)

OBJECTIVE

To characterize the preferred ptosis practice patterns and variations among oculoplastic surgeons in the Asia-Pacific region.

METHODS

A web-based questionnaire was sent to both members and non-members registered under the Asia Pacific Society of Ophthalmic Plastic and Reconstructive Surgery (APSOPRS)'s email database. The survey included preoperative testing practices, surgical preferences for adult aponeurotic and congenital ptosis, various surgical techniques (anterior and posterior approach ptosis procedures, and frontalis sling procedures) and postoperative practices.

RESULTS

A total of 386 survey invitations were sent. There was a response rate of 68.7% from respondents from 20 countries in the Asia-Pacific region. There was variation in the preoperative evaluation and management of ptosis. Anterior approach ptosis surgery (96.6%) and frontalis sling procedures (86.8%) were performed by more surgeons than posterior approach ptosis surgery (47.2%). There was a deviation from the traditional frontalis sling procedures for patients with poor levator function.

CONCLUSIONS

Our survey results provide insight into the variation in the assessment and management of ptosis amongst oculoplastic surgeons in the Asia-Pacific region. It also demonstrates some differences between practice patterns in Asia-Pacific and America.

Silicone sling frontalis suspension for congenital ptosis: Outcome of 174 consecutive cases

BACKGROUND

Frontalis suspension (FS) is the treatment of choice in congenital ptosis with poor levator function. We report the surgical outcome of FS using a double triangle configuration of silicone slings in children.

METHODS

A retrospective cohort study of all paediatric patients with simple myogenic congenital ptosis repaired with FS over a 12-year period (2009-2020). Each silicone sling was secured by simple knots. Pre- and post-operative margin reflex distance (MRD₁ ) measurements were determined from clinical photographs using ImageJ Software. Main outcome measures were improvement in eyelid height, eyelid asymmetry, reoperation rate and timing.

RESULTS

One hundred and thirty nine patients (174 eyes) were included, with 35 (25%) having bilateral surgery. Mean (±SD) age was 1.4 ± 1.9 years. Mean follow up time was 32 ± 20.5 months. Sixteen patients (11%) had a history of previous ptosis repair surgery. Mean MRD₁ improved by an average of 1.5 mm. The final MRD₁ in the group of patients who did not have a second procedure was a mean of 2.1 mm. The MRD₁ difference between both eyes in all unilateral cases improved from 2.5 mm preoperatively to 1.2 mm at final visit (p < 0.001). In the 123 cases without a history of previous ptosis surgery, repeat ptosis repair was performed in 37 (30%) patients, 34.9 ± 19.9 months after the initial procedure. Overall, repeat repair was performed in 47 patients (34%).

CONCLUSIONS

Double triangle silicone sling frontalis suspension has a favourable outcome in two-thirds of paediatric patients with simple myogenic congenital ptosis. Failed cases can be addressed with a second repair, using either autogenous fascia lata or a second silicone sling.

Modified levator muscle complex suspension on treating pediatric blepharoptosis with poor Bell's phenomenon

PURPOSE

To evaluate the surgical outcomes of pediatric congenital blepharoptosis with poor Bell's phenomenon (BP) treated with modified levator muscle complex suspension.

METHODS

Forty-two pediatric congenital blepharoptosis patients with poor BP were treated with modified levator muscle complex suspension, and their major surgical outcomes such as marginal reflex distance1 (MRD1), palpebral fissure height (PFH), and postoperative lagophthalmos were retrospectively reviewed.

RESULTS

The mean follow-up was 10.28 ± 9.89 months (range 3-32 Months). Surgical success was achieved in 54 (87.1%) of 62 eyelids at the final visit, including excellent results in 46 (74.2%) eyelids, good results in 8 (12.9%) eyelids, and poor results in 8 (12.9%) eyelids, respectively. The postoperative PFH of affected eyes (7.97 ± 1.47 mm) was significantly improved compared with that before surgery (3.58 ± 1.31 mm). The mean MRD1 was improved from - 1.48 ± 1.36 mm before surgery to 2.94 ± 1.46 mm after surgery. The postoperative MRD1 was ≥ 3 mm in 46 eyelids and < 3 mm in 16 eyelids. The mean lagophthalmos was 1.42 ± 1.20 mm 3 months after surgery. All of the patients presented complete blink postoperatively. Postoperative complications were rarely observed during follow-up. No patient had exposure keratitis, but blepharoptosis recurred in 6 patients (8 eyelids). All patients had satisfactory eyelid symmetry and contour. No complications were observed until the last visit.

CONCLUSIONS

The modified method results complete blink, mild, and quick recovery of lagophthalmos, flexible eyelid motility, stable ocular surface, and it is simple to perform with few complications and a low recurrence rate at 12.9%, which is worth to wide application on poor Bell's phenomenon blepharoptosis.

Combined levator and frontalis muscle advancement flaps for recurrent severe congenital ptosis

BACKGROUND

To evaluate the outcomes of combined levator resection and frontalis muscle advancement for surgical management of recurrent severe congenital ptosis.

DESIGN

Retrospective, nonrandomized interventional case series.

METHODS

A retrospective review was performed of patients who underwent combined levator resection and frontalis muscle advancement for recurrent congenital ptosis between 2017 and 2020. Inclusion criteria were levator function of 4 mm or less and margin reflex distance 1 (MRD1) of 0 mm or less. Main outcome measures were postoperative MRD 1, lagophthalmos, lash angle, and grades of eyelid contour and crease. The outcomes were assessed by reviewing medical charts and photographs.

RESULTS

Thirty-one patients (35 eyelids) met the inclusion criteria. The mean preoperative MRD1 was -1.14 ± 1.56 mm, which improved to 3.93 ± 0.52 mm with an average lagophthalmos of 0.91 ± 0.74 mm at the last follow-up. A total of 91.4% of eyelids had excellent eyelid contour, crease, and eyelash angle at the final follow-up. One eyelid required revision surgery. There were no other significant complications.

CONCLUSIONS

For poor function recurrent congenital ptosis, combining levator resection and frontalis muscle advancement is an effective method that results in long-term correction with cosmetically pleasing outcomes and minimal complications.

The Combined Use of Silicone and Green Braided Polyester ‎Suture (Ethibond) versus ‎Silicone or Ethibond Alone for Frontalis ‎Suspension Surgery in Children

Purpose

Patients and Methods

Results

Conclusion

Maximal levator resection versus Gore-Tex® sling for congenital blepharoptosis with poor levator function

BACKGROUND:

Treating congenital blepharoptosis is often mandatory to clear the visual access and avoid amblyopia; however, when the levator function is poor, achieving a satisfactory long-term outcome is challenging. This study aimed to compare the outcomes of maximal levator resection (MLR) with those of frontalis suspension (FS) using Gore-Tex ^®, in the treatment of congenital blepharoptosis with poor levator function.

PATIENTS AND METHODS:

The study included 102 eyelids of 66 patients of mean age 4.3 ± 1.6 standard deviation (SD) years, randomly divided into two groups (51 eyes each). Group A: FS using Gore-Tex ^®, Group B: MLR. Postoperative outcomes were evaluated at 1, 6 and 12 months. Patients' ophthalmic examination including margin-reflex distance (MRD1) before and after surgery and postoperative complications were recorded.

RESULTS:

At the end of the follow-up, the mean MRD1 increased from 0.3 ± 0.7 SD mm in Group A, 0.4 ± 0.8 SD mm in Group B preoperatively, to 2.7 ± 0.5 SD mm and 2.9 ± 0.7 SD mm, respectively (P < 0.001 in both groups). Results of Group B were significantly higher than Group A (P = 0.047). Success was achieved in 77 eyelids (75.4%), distributed as follows: 36 eyelids (70.6%) in Group A, and 41 eyelids (80.1%) in Group B. The total recurrence rate was 6.9% (seven eyes), while other complications were recorded in 23 eyes (22.5%).

CONCLUSION:

MLR, compared to FS with Gore-Tex^® sling, can be a more efficient surgical option to correct congenital blepharoptosis with poor levator excursion. Prominent postoperative lagophthalmos warrants close ocular surface observation in early follow-up weeks.

Improved Eyelid Muscle Tension Balance With Refined Frontalis Muscle Flap Suspension in the Treatment of Severe Ptosis

BACKGROUND

The tension balance of the upper eyelid following ptosis repair is crucial to a successful postoperative outcome. To improve on existing surgical techniques, the authors developed a new refined frontalis muscle flap suspension (FMFS) for severe ptosis repair and explored the balancing effect between the orbicularis muscle and frontalis muscle following surgery.

METHODS

Forty-three patients (47 eyes) with a mean age of 6.07 ± 2.55 years old were diagnosed with severe congenital ptosis and underwent refined FMFS with complete orbicularis preservation between January 1, 2010 and December 31, 2017 in the Wenzhou Eye Hospital, Wenzhou, China. The outcomes measured include upper eyelid margin reflex distance (MRD1), degree of lagophthalmos, and cosmetic outcome (lash angle, eyelid contour, and crease). Surgical complications were also recorded.

RESULTS

The preoperative mean MRD1 was -1.29 ± 0.88 mm and preoperative levator function was 1.87 ± 0.82 mm (ranged from 0 to 3.0 mm). Following surgery, lagophthalmos was observed in all cases in the first week with a mean palpebral fissure height of 1.68 ± 0.40 mm and diminished over 3 months. The MRD1 improved to +3.04 ± 0.68 mm at 6 months following surgery. All cases showed excellent cosmetic outcomes. There were no significant complications.

CONCLUSION

The refined FMFS is a safe and reliable surgery in treating severe ptosis. The eye-closing power of the intact orbicularis muscle is sufficient at countering the lifting power of the frontalis muscle suspension, achieving a balanced blink mechanism and eyelid closure.

Minimally invasive harvesting fascia lata (FL) in ophthalmic plastic surgery

PURPOSE

To describe a minimally invasive technique of harvesting fascia lata, and also to analyze the clinical uses and the outcome of fascia lata in Ophthalmic Plastic and Reconstructive surgery.

METHODS

This interventional study was done in three tertiary care eye hospitals in Bangladesh from July 2014 to June 2020. We obtained autologous fascia lata for the correction of congenital ptosis with poor levator function (⩽4 mm), covering the ciliary staphyloma, repair of the extruded implant following anophthalmic socket surgery, and was also used to wrap the orbital implant after enucleation. Preserved FL was used only for children before 6 years of age for the treatment of congenital ptosis.

RESULTS

Out of 60 subjects, 38 (63.3%) were male and 22 (36.7%) were female. Autogenous fascia lata was used for frontalis brow suspension (FBS) in 25 (41.67%) patients of congenital ptosis with poor levator function, as patch graft in ciliary staphyloma (11 cases, 18.3%), to wrap orbital implant following enucleation in intraocular malignancies (nine cases, 15%), to repair of implant extrusion following evisceration (five cases, 8.3%), and as fascial sling to correct recurrent paralytic ectropion (one case, 1.67%). Allogeneic or preserved fascia lata was used to correct congenital ptosis in patients less than 6 years of age (nine cases, 15%). Mean follow-up time was 5.32 months.

CONCLUSION

Fascia lata (autogenous and allogeneic preserved) has varied uses in ophthalmic plastic surgery. Harvesting fascia lata (FL) using with minimally invasive method was successful with the least scar on the thigh to correct congenital ptosis, ciliary staphyloma, repair of extruded implant, and in wrapping implant after enucleation to get better cosmesis and motility.

Combination of Dermal fat Grafting and Frontalis Suspension Using Polytetrafluoroethylene Sheet for Blepharoptosis With a Deep Sulcus

ABSTRACT

The frontalis suspension procedure is a common surgical method for patients with severe blepharoptosis. While frontalis suspension is a very effective method, the transplant material may be visualized after surgery in patients with a deep sulcus and severe blepharoptosis. To prevent this complication, we performed a combination of dermal fat grafting and frontalis suspension using a polytetrafluoroethylene sheet in 5 patients (6 eyelids). We followed-up the patients for at least 6 months postoperatively (mean: 6.8 months) and observed no transplant material visualization or occurrence of infection. The mean pre- and postoperative margin reflex distance-1 was -3.75 (-5 to -2) and 2.10 (1-3), respectively. Bulky upper eyelids were observed 6 months postoperatively in 1 patient (2 eyelids). None of the patients underwent reoperation. In conclusion, the combination of frontalis suspension using a polytetrafluoroethylene sheet and dermal fat grafting for severe blepharoptosis and a deep upper eyelid sulcus was effective in preventing visualization of the transplant material.

OURS RESULTS OF WHITNALL SLING IN PATIENT WITH CONGENITAL MYOGENIC PTOSİS

Amaç: Levator fonksiyonu kötü doğumsal üst gözkapağı düşüklüğünde whitnall askılama ameliyatı uyguladığımız hastaların klinik özelliklerini ve cerrahi sonuçlarını sunmak. Yöntemler: XXX Hastanesi'nde 2003-2005 yıllarında whitnall askı cerrahisi uygulanan 11 hastanın 15 gözü çalışmaya alındı. Hastaların dördü kadın, yedisi erkek olup, yaşları 5 ile 40 yıl arasındaydı. Gözkapağı düşüklüğü dışında sistemik ve oküler patolojileri olanlar çalışmaya alınmadı. Tüm hastalarda anterior yaklaşımla kapak kıvrım insizyonu ile whitnall askı cerrahisi uygulandı. Üst gözkapağı konturunun düzenli olması, kapak çizgisinin simetrik olması şartıyla, tam düzeltme ve bir mm’den az kapak düşüklüğü olanlar ‘başarılı’, 1-2 mm kapak düşüklüğü olanlar ‘tatminkar’, iki mm den daha fazla kapak düşüklüğü olanlar ‘başarısız’ olarak değerlendirildi. Bulgular: Ameliyat sonrası 6. ayda hiçbir hastada kapak kontür düzensizliği ve enfeksiyon gibi komplikasyonlar izlenmedi. Bir hastada iki mm'den fazla kapak düşüklüğü nedeni ile başarısız kabul edildi. Bir hasta ise 1-2 mm arasında kapak düşüklüğü olmasına rağmen optik aks açık olduğu için tatminkar olarak değerlendirildi. Dokuz hastanın 13 gözünde (%86.7) ise bir mm'nin altında kapak düşüklüğü vardı ve sonuç başarılı olarak değerlendirildi. Sonuç: Kötü levator fonksiyonlu hastalarda whitnall askı cerrahisi başarı oranı yüksek ve komplikasyon oranı düşük bir tekniktir. Uzun dönem sonuçlar için karşılaştırmalı geniş serili prospektif çalışmalara ihtiyaç vardır.

Ultra-strong bio-glue from genetically engineered polypeptides

The development of biomedical glues is an important, yet challenging task as seemingly mutually exclusive properties need to be combined in one material, i.e. strong adhesion and adaption to remodeling processes in healing tissue. Here, we report a biocompatible and biodegradable protein-based adhesive with high adhesion strengths. The maximum strength reaches 16.5 ± 2.2 MPa on hard substrates, which is comparable to that of commercial cyanoacrylate superglue and higher than other protein-based adhesives by at least one order of magnitude. Moreover, the strong adhesion on soft tissues qualifies the adhesive as biomedical glue outperforming some commercial products. Robust mechanical properties are realized without covalent bond formation during the adhesion process. A complex consisting of cationic supercharged polypeptides and anionic aromatic surfactants with lysine to surfactant molar ratio of 1:0.9 is driven by multiple supramolecular interactions enabling such strong adhesion. We demonstrate the glue's robust performance in vitro and in vivo for cosmetic and hemostasis applications and accelerated wound healing by comparison to surgical wound closures.

Minimal Dissection Direct Frontalis Muscle Advancement Flap for Congenital Ptosis Repair

BACKGROUND

Frontalis flap advancement is an alternative means of congenital ptosis repair from frontalis suspension utilizing autologous fascia or allogenic implants. Variations in technique, including flap division, location and number of skin incisions, and dissection planes, are described in the literature.

MATERIALS AND METHODS

A retrospective case series of patients with congenital myogenic ptosis treated with simplified, minimal dissection frontalis flap advancement involving a single upper eyelid crease incision with dissection in the preseptal and subcutaneous planes without division to mobilize the frontalis flap. Inclusion criteria: pediatric patients age < 18 years with either primary or recurrent congenital ptosis following previous surgical repair. Exclusion criteria: ptosis of neurogenic etiology or postoperative follow-up < 3 months. Primary outcome measures were postoperative margin-reflex distance 1 (MRD1), the difference in MRD1 between surgical and nonsurgical eyelids in unilateral ptosis, and lagophthalmos. Secondary outcome measures included recurrence and complications.

RESULTS

Twenty-six patients met inclusion criteria, 24 males and 2 females. Mean postoperative MRD1 at last follow-up was 2.9 ± 1.2 mm and the mean difference in MRD1 between surgical and nonsurgical eyelids at last follow-up was 1.1 ± 1.0 mm. Average lagophthalmos at postoperative month 2 to 5 was 0.6 ± 0.7 mm. One patient demonstrated postoperative lid retraction that required re-operation. Four of 31 eyelids (12.9%) demonstrated ptosis recurrence at 5, 12, or 24 months.

CONCLUSIONS

In this retrospective series, the authors report clinically and statistically significant surgical eyelid height improvement and symmetry between nonsurgical and surgical eyelids in congenital ptosis patients treated with minimal dissection direct frontalis flap advancement.

The Function-Preserving Frontalis Orbicularis Oculi Muscle Flap for the Correction of Severe Blepharoptosis With Poor Levator Function

BACKGROUND

Severe blepharoptosis with poor levator function (LF) has traditionally been managed with exogenous frontalis suspension but complications such as lagophthalmos, infection, and rejection are often reported.

OBJECTIVES

The aim of this study was to design a function-preserving frontalis orbicularis oculi muscle (FOOM) flap to correct severe blepharoptosis with poor LF. The long-term surgical outcome of the technique was assessed.

METHODS

This retrospective study included only adult patients with severe blepharoptosis and poor LF, all of whom had their surgery performed by the senior surgeon over a 6-year period. Clinical assessment of LF, palpebral fissure height (PFH), marginal reflex distance 1 (MRD1), duration of follow-up, and postoperative complications were recorded.

RESULTS

A total of 34 patients and 59 eyelids were recorded during a mean follow-up period of 17.7 months. Postoperative evaluation yielded mean [standard deviation] improvements of PFH gain of 5.62 [1.61] mm (P < 0.001), and MRD1 and PFH increases of 4.03 [0.82] mm (P < 0.001) and 8.94 [0.81] mm (P < 0.001), respectively. All patients demonstrated normalization of orbicularis function: no lagophthalmos was observed at the 8-month postoperative follow-up. Recurrence of ptosis was recorded in 4 eyelids (6.78%). Revisions were performed in 2 eyelids (3.39%). No infection or granuloma was noted.

CONCLUSIONS

The function-preserving FOOM flap is a useful vector for frontalis suspension. Not only does it effectively address lagophthalmos as well as other complications, but it provides aesthetically pleasing outcomes in patients with severe blepharoptosis and poor LF.

LEVEL OF EVIDENCE: 4

Treatment of Congenital Ptosis in Infants With Associated Amblyopia Using a Frontalis Muscle Flap Eyelid Reanimation Technique

PURPOSE

To determine the efficacy of a frontalis muscle flap eyelid reanimation technique for correction of severe congenital ptosis and associated amblyopia in infants.

METHODS

The authors performed a retrospective chart review of patients 12 months of age or younger with unilateral or bilateral congenital ptosis and associated amblyopia or deemed at high risk for amblyopia due to visual deprivation. Following ptosis repair via a frontalis muscle flap technique, primary outcomes of postoperative eyelid position and amblyopia reversal were assessed.

RESULTS

Seventeen eyes of 12 participants were included for study. Seven of these patients had simple congenital ptosis, and the remainder had ptosis as part of a syndrome. Nine were diagnosed with amblyopia preoperatively, and the remaining 3 were too young for acuity testing but had occlusion of the visual axis by the ptotic eyelid in primary gaze. Postoperatively, the mean margin-to-reflex distance 1 was 2.4 mm (range: 0.0-4.0), and 9 patients (75%) demonstrated no evidence of amblyopia. Only 2 patients had eyelid asymmetry greater than 2 mm, which in both cases was due to lack of frontalis activation by the patient secondary to ongoing visual impairment. The most common complication was lagophthalmos in 6 eyes (35.3%), with no significant associated surface keratopathy.

CONCLUSIONS

The frontalis muscle flap technique may offer a new and effective approach to treating infants with severe congenital ptosis causing poor eyelid excursion and associated amblyopia while avoiding use of an implant.

The Application of Temporal-Fasciae-Complex Sheet in Treating Severe Blepharoptosis

AIM

To introduce the application of the temporal-fasciae-complex sheet in treating severe blepharoptosis by frontalis suspension and evaluate its postoperative effect.

METHODS

Between 2008 and 2016, 25 patients (33 eyelids) underwent this procedure. A 3-cm incision in the temporal region was made to harvest a sheet of deep temporal fascia with the loose aponeurosis attached on both sides. The sheet was then grafted through a preseptal tunnel to perform the suspension. The margin reflex distance 1 after suspension (MRD1S), the margin reflex distance 1 as lifting eyebrow forcefully (MRD1F), the eyelid excursion and the closable eyelid function were used to evaluate the postoperative effect.

RESULTS

A total of 22 patients (30 eyelids) completed the study with a mean follow-up period of 23 ± 8.78 months. There was a statistically significant difference between the MRD1 and MRD1S (p < 0.05), the preoperative and postoperative MRD1F (p < 0.05), the preoperative and postoperative eyelid excursion (p < 0.05). All the upper palpebral margins were located above the pupils and no longer affected visual acuity in primary gaze. No severe complication and recurrence were documented within a maximum follow-up period of 36 months.

CONCLUSIONS

Frontalis suspension with the temporal-fasciae-complex sheet is an efficient method to correct severe blepharoptosis with less complications and recurrences. The application of the sheet can not only overcome the influence of adhesion but also lift the eyelid both functionally and cosmetically.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Double Rectangle Fascia Lata Frontalis Sling: A Rationale Approach for Ptosis

Background  The purpose of this study was to evaluate the functional outcomes of a modified technique of double rectangle pattern for correction of severe ptosis.

Methods  This is a retrospective study over a period of 8 years including patients who underwent correction of ptosis by double rectangle using autologous fascia lata sling. Surgical outcomes were assessed postoperatively by distance from the corneal light reflex to the upper eyelid margin (MRD1) and levator function.

Results  Twenty-six eyelids were operated in 20 patients. There were 9 males and 11 females, with age ranging from 4 to 35 years. Preoperatively, all patients had poor MRD1 and poor levator function. Postoperative MRD1 was good in 13 patients (17 eyelids), fair in 5 (7eyelids), and poor in 2 patients (2 eyelids). Postoperative levator function was excellent in 12 patients (15 eyelids), good in 6 (9 eyelids), and fair in 2 patients (2 eyelids). At a mean follow-up of 12 months, adequate correction was achieved in 24 eyelids, and 2 eyelids had undercorrection.

Conclusion  Frontalis sling with a double rectangle is simple and more efficient, as it provides a straight line of pull to the eyelid for correction of severe ptosis.

Safety and Efficacy of the Under-Corrected Frontalis Sling in Myogenic Ptosis Accompanying Extraocular Muscle Paralysis

OBJECTIVE

The surgical treatment of myogenic ptosis accompanying extraocular muscle paralysis is an intractable problem in the field of oculoplastic surgery due to the severe complications such as exposure keratopathy. It is promising to find an appropriate procedure to treat this kind of patients, which is able to ensure the safety and efficacy.

METHODS

The authors retrospectively reviewed 12 eyes of 6 patients who underwent the under-corrected "double V-Loop" frontalis suspension sling procedure for myogenic ptosis accompanying extraocular muscle paralysis and access the safety and efficacy of this kind of surgery. All the patients underwent corneal fluorescein staining and confocal microscopy before and after the surgery to inspect the corneal condition. The density of central corneal epithelial cells and endothelial cells were observed.

RESULTS

After the surgery, the eyelids contour was natural, and the symmetry was achieved in these cases. The average palpebral fissures height changed from 2.75 ± 1.41 mm to 4.50 ± 0.35 mm (P = 0.0007) and margin reflex distance 1 changed from -1.25 ± 1.22 mm to +0.50 ± 0.35 mm (P = 0.0002). Out of 12 operated eyes, mild postoperative lagophthalmos was present in 4 cases but without exposure keratopathy during the follow-up, the confocal microscopy showed that there were no significant differences in central corneal superficial epithelial cells (P = 0.93) and endothelial cells (P = 0.90) before and after the surgery.

CONCLUSION

The under-corrected "double V-Loop" frontalis suspension sling is a proper surgery in myogenic ptosis accompanying extraocular muscle paralysis, which leads to a low occurrence of exposure keratopathy, maintains the integrity of the cornea, and remains the patients' vision function.

Single-triangle versus Fox pentagon frontalis suspension for unilateral severe congenital ptosis correction

PURPOSE

To compare the functional and cosmetic outcomes of two different frontalis sling techniques for correction of severe unilateral congenital ptosis: single triangle and Fox pentagon techniques using expanded polytetrafluoroethylene (ePTFE) suture.

METHODS

This randomized controlled trial included 60 eyes of 60 patients with severe unilateral simple congenital ptosis and poor levator function (≤4 mm). Participants were randomly assigned for either single triangle or Fox pentagon frontalis suspension using ePTFE suture. Functional outcome measures were margin reflex distance (MRD1), palpebral fissure height (VFH), and lagophthalmos. Cosmetic outcome parameters (lid contour, lid crease, and height symmetry) were graded as 3 (excellent), 2 (good), or 1 (poor), with a minimum of 18 months' follow-up.

RESULTS

At final follow-up, there was a significant improvement in the MRD1 and VFH in both groups, with no statistical difference (P = 0.9). Both groups showed comparative cosmetic results regarding lid height symmetry, crease, and contour. The patients in the single-triangle group showed more rapid recovery of postoperative edema and lagopthalmos with less visible forehead scarring. There were no serious ePTFE sling-related complications.

CONCLUSIONS

In our study cohort, the single-triangle and Fox pentagon frontalis suspension techniques had similar outcomes with respect to MRD1 and VFH and comparable cosmetic results. However, the single-triangle technique avoids two forehead incisions and was associated with less postoperative edema, lagophthalmos, and scarring.

Eyebrow Elevation as a Prognostic Factor for Success of Frontalis Suspension in Severe Congenital Ptosis

Purpose

The study aims at evaluating eyebrow elevation as a prognostic factor for frontalis sling procedure success in patients suffering from severe congenital ptosis with poor levator function.

Patients and Methods

This is a retrospective study that included 66 eyelids of 57 patients selected from a surgical log database between January 2016 and June 2019. All of them underwent frontalis suspension surgery for treating severe congenital myogenic ptosis with poor levator function. Based on the absence or presence of brow elevation, patients were divided into two groups: 1 and 2, respectively. The latter was further subdivided into subgroup A with unilateral brow elevation and subgroup B with bilateral brow elevation. All included cases completed 6 months of follow-up after surgery. Postoperative functional outcomes in the form of margin reflex distance (MRD1) and palpebral aperture (PA) were recorded and correlated to preoperative brow elevation status.

Results

Both principal groups showed improvement of MRD1 and PA compared to the preoperative values. There was no statistically significant difference between both groups for the tested parameters in the 1st postoperative week. By the 6th postoperative month, MRD1 and PA showed statistically significant higher values in group 2 compared to group 1 (p<0.001). However, the difference between subgroups A and B was statistically insignificant for the same parameters.

Conclusion

Eyebrow elevation is significantly associated with the success of frontalis suspension procedure. Hence, brow position evaluation should be included in the preoperative assessment of patients undergoing frontalis suspension for congenital ptosis.

The Effect of Two Different Frontalis Sling Approaches on Postoperative Eyelid Contour: A Comparative Study

PURPOSE

To compare two different frontalis sling approaches, tarsal fixation and orbicular muscle fixation, using silicone rod (FCI Ophthalmics, Marshfield Hills, MA, USA) in terms of postoperative upper eyelid contour in patients with poor levator muscle function.

DESIGN

Retrospective, comparative, case series.

METHODS

Ten eyes of seven patients who received frontalis sling surgery with orbicularis muscle fixation (group 1), eight eyes of seven patients who received frontalis sling surgery with tarsal fixation (group 2) and 30 eyes of 15 age and sex-matched healthy controls (control group) were included. Postoperative photographs of all the participants were taken in the primary gaze, and each photograph was viewed on a computer. The distance between the upper lid margin and pupillary center (MCD), nasal limbus (MND), and temporal limbus (MTD) was measured, respectively, using the ruler in Microsoft Paint Software and compared with each other for each participant.

RESULTS

Both nasal, central and temporal margin distance values in group 1 and group 2 were significantly lower than those of the control group (p < 0.05 for all values). The ratio of MTD/MCD in the control group was significantly higher than group 1 (p = 0.04) besides the ratio of MND/MTD in the control group was significantly lower than group 1 (p = 0.01).

DISCUSSION

Frontalis sling approach with tarsal fixation using silicone rod might provide improved cosmetic results including more symmetrical upper eyelid contour compared with orbicularis muscle fixation approach. Moreover, the novel measuring technique presented in the current study provides a simple and effective assessment of the upper lid contour in daily practice setting.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

[Treatment of congenital ptosis in a low-income country: polypropylene frontalis sling at the African Institute of Tropical Ophthalmology]

INTRODUCTION

Treatment of congenital ptosis is exclusively surgical; the frontalis sling method is most appropriate when the ptosis is severe, with no upper eyelid levator function. This surgery typically utilizes various materials (autologous fascia lata, silicone, nylon, or polypropylene bands, etc.).

MATERIALS AND METHODS

This was a retrospective descriptive study of 22 children under 16 years of age, treated for congenital ptosis by frontalis suspension of the levator muscle of the upper eyelid using the polypropylene technique, between January 1, 2014 and June 30, 2017 at the African Institute of Tropical Ophthalmology teaching hospital.

RESULTS

In our study, the surgical result (prior to correction of recurrences) was satisfactory in 81.82 % of cases, with a recurrence rate of 13.64 %. The mean follow-up was 14 months, ranging from 4 to 25 months.

DISCUSSION

The use of polypropylene provides encouraging results in ptosis surgery, while also offering the advantage of being low cost and more available. Its use in developing countries deserves special attention.

Factors related to amblyopia in congenital ptosis after frontalis sling surgery

Background

Amblyopia is a main concern in children undergoing frontalis sling surgery for repairing congenital ptosis. This study aimed to evaluate factors related to amblyopia in children undergoing frontalis sling surgery.

Methods

IRB-approved retrospective review of children under the age of 12 who received frontalis sling surgery. Preoperative demographic data, strabismus, margin reflex distance 1 (MRD1), lid fissure height, sling type, refraction errors, surgical outcome and amblyopia were evaluated.

Results

This study included 48 eyelid procedures performed in 38 patients. Median age was 4.0 years. Etiology was congenital ptosis in 42 eyes (87.5%) and blepharophimosis in 6 eyes (12.5%). Mersilene mesh was the sling material used in 36 eyes (75%), silicone in 6 eyes (12.5%), and polytetrafluoroethylene (PTFE) in 6 eyes (12.5%). Mean duration of follow-up was 27.8 ± 25.0 months (range, 3 to 128 months). Amblyopia was observed in 17 eyes (35.4%) at the final follow-up. Factors significantly associated with final amblyopia included blepharophimosis (p = 0.017), preoperative MRD1 ≤ − 1.0 mm (p = 0.038), preoperative lid fissure ≤4.5 mm (p = 0.035), preoperative anisometropia (spherical equivalent) (p = 0.011), and postoperative astigmatism (p = 0.026).

Conclusions

Study results suggest that blepharophimosis, preoperative MRD1 ≤ − 1.0 mm, preoperative lid fissure ≤4.5 mm, preoperative anisometropia (spherical equivalent), and postoperative astigmatism are associated with amblyopia after frontalis sling surgery in patients with congenital ptosis.

Outcomes of Frontalis Sling Versus Levator Resection in Patients With Monocular Elevation Deficiency Associated Ptosis

PURPOSE

To compare outcomes of frontalis sling (FS) silicone and levator resection (LR) in ptosis associated with monocular elevation deficiency.

METHODS

Retrospective interventional comparative case series of FS and LR in monocular elevation deficiency associated ptosis. Favorable outcome was defined as difference in margin reflex distance 1 of ≤1 mm between the 2 eyes in unilateral cases and margin reflex distance 1 of 4 mm in bilateral cases at last follow-up visit.

RESULTS

One hundred four eyes of 95 patients were included. Median age at surgery was 14 years, and the mean follow-up period was 19.75 ± 34.55 months. Ptosis was severe in 91 (87.5%) patients. Associated Marcus Gunn jaw-winking (MGJW) phenomenon was seen in 43 (42%) patients. Frontalis sling was performed in 76 (73%) and LR in 28 (27%). Mean pre- and postoperative margin reflex distance 1 were -1.27 ± 2.17 mm and 2.18 ± 1.49 mm (p < 0.0001). The mean improvement in margin reflex distance 1 was significantly more with FS (4.46 ± 2.19) compared with LR (1.85 + 2.5) (p < 0.0001). There were no cases of exposure keratopathy requiring reversal of surgery in either group. The number of resurgeries required was 42 (55%) in the FS group and 10 (36%) (p = 0.08) in the LR group. Favorable outcome was seen in 54 (71%) in FS group and 16 (57%) (p = 0.17) in LR group.

CONCLUSIONS

When compared with levator resection, frontalis suspension with silicone gives a better eyelid elevation but has greater regression requiring more resurgeries. In spite of a poor Bells phenomenon, exposure keratopathy is not a concern.

Surgical treatment of severe congenital ptosis using deep temporal fascia

Purpose: To evaluate the surgical outcome of a frontalis sling using deep temporal fascia in the treatment of severe congenital ptosis (SCP). Methods: A retrospective, interventional case series was performed. The study involved 25 patients with SCP (>4 mm). All patients underwent frontalis sling surgery with deep temporal fascia between 2004 and 2012 with a follow-up period of 12 months at a minimum. Data regarding eyelid position, eyelid symmetry, cosmetic outcomes, and postoperative complications were evaluated. Results: The mean age at surgery was 7.68 years (range 4-17 years) with an average follow-up of 60 months (range is 12-108 months). The functional success rate was 88% (22/25). Ptosis recurred in 8% (2/25) of patients, overcorrection was present in 4% (1/25) of patients. The patients with ptosis recurrence underwent reoperation. The preoperative margin-to-reflex distance (MRD1) was -0.85±0.87 mm (range, -2.5 to + 0.5 mm), while the postoperative MRD1 was + 2.1 ± 1.05 mm (range, -1.5 to + 4 mm) (p < .0001). Lid symmetry (asymmetry < of 1 mm of MRD1 between the two eyes) was present in all the successful cases. Postoperative complications included transient exposure keratopathy (32%) and inflammatory brow reaction (8%). Conclusions: Frontalis sling operation with deep fascia temporalis is very effective in the treatment of SCP with excellent long-term functional and cosmetic successes.

Pediatric Frontalis Suspension With Braided Polyester: A Comparison of Two Techniques

PURPOSE

To demonstrate the benefits of using braided polyester in the management of severe or recurrent ptosis in children and young adults and to compare the efficacy of two surgical techniques.

METHODS

Retrospective, non-randomized record review of 30 patients (43 eyelid procedures) affected by congenital or acquired severe ptosis who underwent frontalis suspension with braided polyester from 2008 to 2016. Two surgical techniques were compared: the base-down triangle and the Fox pentagon, both of which were performed using a closed technique. Functional success was defined as clearing of the visual axis. Complications and results were examined.

RESULTS

Functional success was obtained in 39 eyes of 43 procedures. Marginal reflex distance increased an average of 2.51 mm with the base-down triangle technique and 1.70 mm with the Fox pentagon technique (P = .05). The vertical palpebral fissure height increased an average of 4.60 mm with the base-down triangle technique and 2.45 mm with the Fox pentagon technique (P < .001). Mean follow-up duration was 38.6 months. Complications included untied suture (n = 2), suture dehiscence (n = 1), cellulitis (n = 2), and granuloma (n = 1).

CONCLUSIONS

Braided polyester was found to be a safe, effective, easy-to-handle, and low-cost sling material for frontalis suspension and should be considered for clinical use, especially in developing countries where the cost and availability of other materials represents a significant barrier to treatment. In the authors' experience, the base-down triangle technique appeared superior to the Fox pentagon technique. [J Pediatr Ophthalmol Strabismus. 2018;55(4):229-233.].

Revision Surgery for Undercorrected Blepharoptosis After Frontalis Sling Operation Using Autogenous Fascia Lata

PURPOSE

Undercorrected blepharoptosis can be encountered after frontalis sling operation. Revision surgery for undercorrection has commonly involved introducing a new sling material. We describe and evaluate a simple surgical technique to correct undercorrection by adjusting preexisting fascia.

METHODS

This is a retrospective interventional case series of patients undergoing sling revision between February 2010 and February 2017. Skin incision was made on the previous incision line. Careful dissection was performed superiorly to identify a preexisting fascia, and the dissected fascia was reattached to the tarsal plate using nonabsorbable sutures with adjustments for eyelid height and contour. The success of the procedure was defined as less than 1 mm of difference in the marginal reflex distance 1 of both eyes without any contour deformity.

RESULTS

Twenty-one eyelids in 18 patients were included with a mean follow-up of 17.5 months (range 6-48) and a mean age of 14.7 years (range 5-57). All patients had undergone frontalis sling with autogenous fascia lata for congenital ptosis. Undercorrection due to recurrent ptosis was found in 12 eyelids, and contour deformity such as temporal ptosis was found in 9 eyelids. The mean time interval between previous frontalis sling operation and sling revision was 6.8 years. Nineteen patients (90.5%) achieved surgical success and a cosmetically acceptable appearance.

CONCLUSION

Sling revision is a simple and effective method with low perioperative morbidity for cases of undercorrection or contour deformity following frontalis sling operation using autogenous fascia lata, even long after the primary procedure.

Surgical treatment of unilateral severe simple congenital ptosis

Unilateral congenital ptosis with poor levator function of ≤4 mm continues to be a difficult challenge for the oculoplastic surgeon. Surgical correction can be accomplished with unilateral frontalis suspension, maximal levator resection, or bilateral frontalis suspension with or without levator muscle excision of the normal eyelid. Bilateral frontalis suspension was proposed by Beard and Callahan to overcome the challenge of postoperative asymmetry, allowing symmetrical lagophthalmos on downgaze, postoperatively. However, most surgeons and patients prefer unilateral correction on the abnormal eyelid either with a frontalis suspension or maximal levator resection. Frontalis suspension may be performed through the various surgical techniques using different autogenous or exogenous materials. Autogenous fascia lata is considered the material of choice with low recurrence rates but carries the drawbacks of the difficulty of harvesting and postoperative morbidity from the second surgical site. Recent reports have suggested that maximal levator resection provides improved cosmesis, a more natural contour, and avoids brow scars. Although both treatments have shown to have similar success rates, there is much debate about what the most favorable method for treating severe unilateral ptosis. We review the literature on the various surgical treatments for unilateral severe congenital ptosis, including the rationale, advantages and disadvantages of each technique.

Double Rhomboid Suture Technique for Congenital Ptosis

PURPOSE

Congenital ptosis is a troubling eye condition for pediatric ophthalmologists. There are many considerations to contemplate when deciding when to operate and which technique to use.

METHODS

A retrospective chart review of 69 pediatric patients treated for congenital ptosis using a double rhomboid frontalis sling with a nylon suture at a single tertiary care center.

RESULTS

For patients with more than 6 months of follow-up, there were 38 patients with 46 primary surgeries (22 [58%] males and 16 [42%] females). The average age at the first surgery was 39.34 ± 33.18 months. There was a mean follow-up time of 51.87 ± 53.79 months. There were 7 children who needed one revision and 1 child who needed a second revision, equaling a 23.9% rate of revision. Patients who had surgery before the age of 3 years had a statistically significant likelihood of needing a second surgery (chi-square test = 7.246, P = .007, 95% confidence interval = 0.027 to 0.687). It was also statistically significant (P < .05) that, throughout childhood, older patients were less likely to need a revision.

CONCLUSIONS

A double rhomboid frontalis sling using a nylon suture is an effective technique to treat congenital ptosis. This technique is easy to master and has a low cost compared to techniques involving autografts and allografts. It is also important to advise the family of the likelihood of a second surgery if there is a need to operate at a young age. [J Pediatr Ophthalmol Strabismus. 2018;55(2):117-121.].

Endoscope-assisted harvest of autogenous fascia lata in frontalis suspension surgery: A minimally invasive approach revisited

Purpose:

To report endoscope-assisted fascia lata harvest (EAFH) as a minimally-invasive technique for correction of severe blepharoptosis.

Methods:

This was a retrospective case series between January 2013 and April 2017. Medical records of all consecutive patients who underwent frontalis suspension by EAFH in the study period were reviewed and outcome was analyzed.

Results:

Fourteen patients (10 males) were included in the study. Mean age of the group was 18.14 + 17.03 years (range 4-65 years) and 11 patients had simple congenital blepharoptosis. Blepharophimosis syndrome was seen in 3 patients. Eleven patients had bilateral blepharoptosis. The mean preoperative and postoperative MRD1 was –1.60 ± 0.87 mm and +2.12 ± 1.37 mm respectively. Mean lengths of the incision and fascial harvest were 2.25 ± 0.43 cm and 13.0 ± 2.35 cm (range 10-17 cm) respectively. The median follow-up of patients was 4.57 + 4.03 months (range 1-15 months). Complications included a wound dehiscence in two patients and these were resutured. The donor sites healed well in all patients leaving a small thigh scar and none needed scar revision.

Conclusion:

EAFH is a promising minimally-invasive technique performed with a small incision and achieved adequate length of fascial harvest.

Congenital ptosis repair with a frontalis silicon sling: comparison between Fox's single pentagon technique and a modified Crawford double triangle technique

PURPOSE

To compare the results of two different frontalis sling surgery techniques with silicon rod for ptosis: Fox's single pentagon technique and a modification of Crawford's double triangle technique.

METHODS

In a randomized clinical trial, 52 eyes of 50 patients with severe ptosis and poor levator function (≤4 mm) were randomly assigned to the Fox group or the modified Crawford group. Cosmetic outcome, functional success, and lagophthalmos were compared.

RESULTS

The patients achieved a fair to good cosmetic outcome by subjective grading and a fair outcome by objective grading in both groups. The intergroup difference was not statistically significant (P > 0.05). However, patients with preoperative lateral droop had better cosmetic outcome in the modified Crawford group. Mean increase in marginal reflex distance 1 (MRD-1) was 4.0 ± 1.7 mm in the Fox group and 3.7 ± 1.1 mm in the modified Crawford group. Change in MRD-1 within groups was significant (P < 0.0001); however, the difference in the groups was not (P = 0.44). The mean lagophthalmos in the Fox group was 1.3 ± 0.7 mm versus 0.6 ± 0.7 mm in the modified Crawford group at final follow-up. This intergroup difference in lagophthalmos was statistically significant (P = 0.001).

CONCLUSIONS

Both techniques were effective in reducing the amount of blepharoptosis and achieving a natural appearing cosmetic outcome. In cases with predominant lateral droop, the modified Crawford's technique seems to produce better results, although the small number of cases does not permit statistical comparison.

Clinical Results of Modified Frontalis Suspension Technique Using Preserved Fascia Lata for Congenital Ptosis

PURPOSE

The purpose of this study was to evaluate the clinical results of modified frontalis suspension technique with preserved fascia lata and to analyze the results according to age and preoperative ptosis degree.

METHODS

This study involved a retrospective review of the electronic medical records of congenital ptosis patients who underwent unilateral or bilateral frontalis sling surgery using preserved fascia lata between March 1, 2004 and December 31, 2012.

RESULTS

Seventy-seven patients (99 eyes) were included in the study. The mean age of the patients at the time of surgery was 6.2 ± 6.7 years. Mean follow-up time was 5.4 ± 3.2 years. Among 77 patients, 22 patients (28.5%) had a mild degree of ptosis, 39 (50.6%) had moderate, and 16 (20.7%) had a severe degree of ptosis. A satisfactory result (good and fair) was achieved in 65 of the 77 patients (84.4%) and a poor result was recorded in 12 patients (15.5%). Preoperative ptosis degree had no effect on the surgical success rate (19/22 [86.3%] in the mild group versus 34/39 [87.1%] in the moderate group versus 12/16 [75%] in the severe group, P = 0.243). There was no significant difference in surgical success rate between the unilateral and bilateral ptosis groups (45/55 [81.8%] versus 20/22 [90.9%], P = 0.479 respectively), between sexes (41/46 [89.1%] in male versus 24/31 [77.4%] in female, P = 0.271), or age groups (52/60 [86.6%] in younger group versus 13/17 [76.4%] in elder group, P = 0.526). Recurrence of ptosis did not differ according to the preoperative ptosis degree (3/22 [13.6%] in the mild group, 5/39 [12.8%] in the moderate group, and 2/16 [12.5%] in the severe group, P = 0.994). Age also had no influence on the ptosis recurrence. The preoperative marginal reflex distance 1 of 0.41 ± 1.06 mm increased to 1.67 ± 0.80 mm postoperatively (P = 0.000).

CONCLUSIONS

The authors identified the long-term efficacy of preserved fascia lata in frontalis sling surgery with a modified frontalis suspension method for all age groups of patients. There was a small rate of recurrence (12.9%) over a maximum of 9 years of follow-up, which was corrected with additional surgery.

Spontaneous Blinking Kinematics in Patients Who Have Undergone Autogeneous Fascia Frontalis Suspension

PURPOSE

To measure spontaneous blink metrics and brow motion in patients with congenital ptosis operated with frontalis slings with autogenous fascia lata.

METHODS

An infrared three-dimensional video motion analyzer was employed to simultaneously measure brow motion and spontaneous blinks of 17 patients with congenital ptosis who underwent frontalis sling with autogenous fascia lata and a control group of equal number of healthy subjects. A customized software identified and quantified the amplitude and maximum velocity spontaneous blinks eyelid and brown motion during a 5-minute observation of a commercial movie. The corneal status of the patients with and without lagophthamos was evaluated with slit-lamp biomicroscopy with fluorescein staining.

RESULTS

Lagophthalmos was detected on 13 (76.5%) patients. Out of these 3 (23%) showed signs of inferior superficial keratopathy despite the presence of normal (upwards) Bell's phenomenon in all of them. Blink rate was significantly diminished in the patients. The distribution of interblink time was similar in both groups. The mean amplitude of the down-phase of the patients' blinks was only 38% of the controls. The main sequence slope of the patients' blinks was abnormally low. In controls brow motion was a minute and random event no related to blinks. In the patients, the mean brow amplitude was five times higher than in controls reaching 45% of the blink amplitude.

CONCLUSIONS

Spontaneous blink amplitude and velocity are severely impaired in patients with fascia lata autogenous slings. After surgery blinking amplitude is linearly related to the amplitude of brow motion.

Efficacy of brow suspension with autogenous fascia lata in simple congenital ptosis

Objective:

To assess the mean change in interpalpebral fissure height and marginal reflex distance after brow suspension with autogenous fascia lata sling in patients of ptosis.

Methods:

This was a Quasi experimental study conducted at Department of Ophthalmology, Mayo Hospital, King Edwards Medical University Lahore, from Jan 2013 to June 2016. Included were the patients who had unilateral or bilateral ptosis with poor levator function (< 5 mm). Informed consent was obtained from all patients after explaining about the research project. Patients were admitted in ward and all of them underwent surgery by a single surgical team. The surgical procedure was performed in supine position under general anesthesia in children and uncooperative patients. Patients were followed at week 4, 8, 12 and 24 to observe vertical interpalpebral fissure height and marginal reflex distance.

Results:

The mean age of the patients was 9.03 ± 5.26 years. The mean Inter palpebral fissure height (IPFH) was 4.40±0.91 mm and mean MRD was 0.50 ± 1.00 mm before surgery while after surgery it was 7.41±0.76 mm and 3.10 ± 1.50 mm respectively at 04 weeks. The mean IPFH and MRD at 24 weeks postoperatively were 8.43±0.98 mm and 3.60 + 1.50 mm respectively. The mean change in IPFH and MRD at 24^th week, were 3.90 ± 0.34 mm and 3.50 ± 1.00 mm.

Conclusion:

Brow suspension with fascia lata sling is safe and effective technique for correction of ptosis with poor levator function.