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Landau Prat D, Zhao CS, Ramakrishnan M, Revere KE, Katowitz WR, Katowitz JA. Outcome of silicone sling frontalis suspension in children with simple congenital and complex ptosis. CANADIAN JOURNAL OF OPHTHALMOLOGY 2024; 59:264-269. [PMID: 37364855 DOI: 10.1016/j.jcjo.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/29/2023] [Accepted: 06/05/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVE To compare the outcome of silicone sling frontalis suspension (FS) surgery in children with simple congenital ptosis and children with complex ptosis. DESIGN A retrospective cohort study. PARTICIPANTS All pediatric patients who underwent silicone sling FS surgery between 2009 and 2020 at a single centre. METHODS Patients were divided based on etiology into simple congenital ptosis and complex congenital ptosis. Pre- and postoperative margin-to-reflex distance (MRD1) measurements were determined from clinical photographs. Main outcome measures were assessed as differences in improvement in eyelid height and reoperation rate between the groups. RESULTS Two-hundred and eight children were included: 139 simple and 69 complex cases, with 83 females (40%). Mean (±SD) age at intervention was 1.9 ± 2.9 years. Complex cases included blepharophimosis epicanthus inversus syndrome (n = 35), Marcus Gunn jaw-winking syndrome (n = 12), oculomotor palsy (n = 8), congenital fibrosis of extraocular muscles (n = 3), chronic progressive external ophthalmoplegia (n = 3), and others. Mean MRD1 improved by an average of 1.6 mm in both groups. Repeat ptosis correction was performed in 50 of 171 patients (29%) without a history of failed ptosis procedures, and this rate was similar between simple and complex cases. Children under 3 years of age had higher rates of repeat ptosis repair than older children (n = 59 of 175 [34%] vs n = 5 of 33 [15%]; p = 0.03, χ2 test). CONCLUSIONS Silicone sling FS has a favourable outcome in 70% of pediatric patients. Preoperative and final MRD1 and reoperation rates were similar between both groups, suggesting that despite the higher complexity in atypical cases, the outcome is similar.
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Affiliation(s)
- Daphna Landau Prat
- Division of Ophthalmology, Children's Hospital of Philadelphia and the Edwin and Fannie Gray Hall Center for Human Appearance, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA.; Division of Ophthalmology, Goldschleger Eye Institute and the Sheba Talpiot Medical Leadership Program, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel..
| | - Cindy S Zhao
- Division of Ophthalmology, Children's Hospital of Philadelphia and the Edwin and Fannie Gray Hall Center for Human Appearance, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Meera Ramakrishnan
- Division of Ophthalmology, Children's Hospital of Philadelphia and the Edwin and Fannie Gray Hall Center for Human Appearance, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Karen E Revere
- Division of Ophthalmology, Children's Hospital of Philadelphia and the Edwin and Fannie Gray Hall Center for Human Appearance, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - William R Katowitz
- Division of Ophthalmology, Children's Hospital of Philadelphia and the Edwin and Fannie Gray Hall Center for Human Appearance, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - James A Katowitz
- Division of Ophthalmology, Children's Hospital of Philadelphia and the Edwin and Fannie Gray Hall Center for Human Appearance, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
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Ahmad R, Rehman U, Sohaib Sarwar M, Ahmed Z, Adebayo O, Brennan PA. Use of autogenous fascia lata slings in the surgical correction of ptosis: a systematic review of the literature and meta-analysis. Br J Oral Maxillofac Surg 2024; 62:128-139. [PMID: 38290862 DOI: 10.1016/j.bjoms.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 11/28/2023] [Indexed: 02/01/2024]
Abstract
Ptosis is an abnormally low-positioned upper eyelid. Management depends on severity, aetiology, and function of the levator palpebrae superioris muscle (LPS). This review evaluates the success of autogenous fascia lata slings (AFLS) in the surgical management of ptosis, together with complication and reoperation/revision rates. A literature search was conducted on PubMed, Google Scholar PROSPERO, Dynamed, DARE, EMBASE, Cochrane, and BMJ databases (PROSPERO registration: CRD42023475090), and 30 studies (3690 patients and 5059 eyes) were included. The average age of the patients was 14.2 years with a ratio of male:female patients of 1:0.7. A total of 2532 eyes had undergone a fascial sling with autogenous fascia lata. The average follow-up period was 32.6 months. Improvement in the margin to reflex distance 1 (MRD1) with fascial sling surgery was 2.79 mm. The rate of complications from surgery involving autogenous fascia lata was 21.3%. The most common complications included lagophthalmos (19.8%), residual ptosis (11.5%), and corneal damage (10.4%). The reoperation rate was 13.4%. Most common indications for reoperation were cosmetic, with asymmetry (18%), lid crease abnormalities (30%), and upper eyelid trimming (18%). The overall complication rate in AFLS patients was 20% (95% CI: 6 to 35, p < 0.01; I2 = 89%) versus 27% (95% CI: 14 to 40, p < 0.01; I2 = 90%) in non-AFLS patients. AFLSs are prudent in the surgical management of ptosis. The results of this review demonstrate that their use is associated with similar complication rates but fewer reoperations than other traditional techniques.
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Affiliation(s)
- Reddin Ahmad
- Core Surgical Trainee 1, Plastic Department, University Hospitals Leicester NHS Trust, Leicester, United Kingdom.
| | - Umar Rehman
- Clinical Research Fellow, UCL Division of Surgery and Interventional Sciences, UCL, London, United Kingdom.
| | - Mohammad Sohaib Sarwar
- Locum Clinical Fellow, Department of Oral and Maxillofacial Surgery, The Queen Victoria Hospital, East Grinstead, United Kingdom.
| | - Zahra Ahmed
- Medical Student, Faculty of Medicine, University of Southampton, Southampton, United Kingdom.
| | - Oluwasemilore Adebayo
- Foundation Doctor, Department of Surgery, Lister Hospital, Stevanage, United Kingdom.
| | - Peter A Brennan
- Honorary Professor of Surgery, Consultant Oral and Maxillofacial Surgeon, Department of Oral and Maxillofacial Surgery, Queen Alexandra Hospital, Portsmouth, United Kingdom.
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Nowak-Gospodarowicz I, Kicińska A, Kinasz M, Rękas M. A new algorithm for the transconjunctival correction of moderate to severe upper eyelid ptosis in adults. Sci Rep 2024; 14:2566. [PMID: 38297133 PMCID: PMC10830490 DOI: 10.1038/s41598-024-52990-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 01/25/2024] [Indexed: 02/02/2024] Open
Abstract
A posterior approach is recommended for the correction of mild to moderate upper eyelid ptosis in adults. The aim of this study is to propose a new algorithm that helps to predict outcomes in the transconjunctival correction of moderate to severe blepharoptosis. This study included adult patients with moderate to severe upper eyelid ptosis treated between 2019 and 2021. Patients meeting inclusion criteria underwent ptosis correction through a posterior approach using an algorithm: 4 mm Mueller's muscle transconjunctival resection to correct 1 mm ptosis (depending on a test with 10% phenylephrine: 3-12 mm) ± tarsal plate resection: 1 mm for every 1 mm of residual ptosis after phenylephrine test, but leaving a minimum of 4 mm upper tarsus intact. Outcomes were ovserved within at least 6-months. Outcomes were assessed based on pre- and postoperative MRD1 changes, inter-eyelid height symmetry, cosmetic effect, and complications. Outcomes of 118 procedures in 81 patients (average age 69, range: 47-87) were analyzed. MRD1 changes were statistically significant, from 0.2 ± 1.6 mm before to 4.1 ± 1 mm after surgery. The function of the levator palpebrae superioris muscle was 10.2 ± 3.4 (range 5-17) mm. Upper eyelid lifted by an average of 1.8 ± 0.7 (range 0-3) mm after the instillation of 10% phenylephrine eyedrops. An average of 8.5 ± 0.8 (range 8-10) mm of conjunctiva and Mueller's muscle and 2.2 ± 0.9 (range 1-5) mm of the tarsal plate were resected during the procedure. Inter-eyelid height symmetry within 1 mm was achieved in 95% of outcomes. The algorithm introduced in this study appears to be useful to achieve repeatable satisfactory outcomes in the transconjunctival correction of moderate to severe upper eyelid ptosis in adults with at least "fair" levator function.
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Affiliation(s)
- Izabela Nowak-Gospodarowicz
- Department of Ophthalmology, Military Institute of Medicine-National Research Institute, 128 Szaserow St, 04-141, Warsaw, Poland.
| | - Aleksandra Kicińska
- Department of Ophthalmology, Military Institute of Medicine-National Research Institute, 128 Szaserow St, 04-141, Warsaw, Poland
| | - Michał Kinasz
- Department of Ophthalmology, Military Institute of Medicine-National Research Institute, 128 Szaserow St, 04-141, Warsaw, Poland
| | - Marek Rękas
- Department of Ophthalmology, Military Institute of Medicine-National Research Institute, 128 Szaserow St, 04-141, Warsaw, Poland
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Diagnosis and Management of Pseudoblepharoptosis in Eastern Asians: A Commonly Observed But Easily Overlooked Type of Blepharoptosis. J Craniofac Surg 2023; 34:498-502. [PMID: 36731095 DOI: 10.1097/scs.0000000000008935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Pseudoblepharoptosis, which is characterized by ptotic eyelid appearance with normal levator function, is a common abnormality observed in Eastern Asians. Misdiagnosis of pseudoblepharoptosis may lead to inappropriate treatments and unwanted complications. Using the data obtained from a modified levator function examination, this study sought to improve the diagnosis and explore the appropriate treatment of pseudoblepharoptosis based on the typical eyelid anatomy of Eastern Asians. METHODS This retrospective study included patients with drooping and bulky eyelids who had been preoperatively diagnosed between January 2018 and December 2018 using a modified approach. Debulking of the retro-orbicularis oculus fat and orbital septum fat and release of the ligament-like structure were performed to correct pseudoblepharoptosis without manipulating the levator muscle. The functional and aesthetic outcomes were evaluated postoperatively. RESULTS The proposed modified approach was significantly more accurate than the traditional technique. Of the patients, 78 (84.8%) and 9 (9.8%) showed good and moderate cosmetic outcomes, respectively. The margin reflex distance 1 value significantly improved from 1.74±0.87 mm preoperatively to 4.56±0.71 mm postoperatively ( P <0.05). Moreover, 179 (97.3%) of the 184 eyelids examined achieved adequate correction. CONCLUSIONS The modified levator function examination approach used in this study may help improve the diagnosis of pseudoblepharoptosis. Surgical intervention focused on correcting the bulky and drooping upper eyelids and orbital septum may lead to satisfactory outcomes in Eastern Asians with pseudoblepharoptosis without manipulating the levator muscle.
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Qiu Y, Jin R, Dong X, Shen Y, Ding F, Deng Z, Zhou X, Ning Y, Yang J, Liu F. Conjoint fascial sheath suspension with levator muscle advancement for severe blepharoptosis. J Plast Surg Hand Surg 2023; 57:533-538. [PMID: 36661892 DOI: 10.1080/2000656x.2023.2168275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
In patients with severe blepharoptosis, the function of the levator muscle is usually weak. Even if a large amount of levator is resected, under-correction and recurrence often occur postoperatively. Frontalis suspension is the first choice for severe ptosis; however, the external orbital lifting force of the frontalis causes non-physiological eyelid movement. Conjoint fascial sheath (CFS) is a fibrous tissue which can provide dynamic movement of upper eyelids and has been applied for the treatment of mild and moderate blepharoptosis in recent years. This study aims to assess the efficacy and safety of CFS suspension combined with levator muscle advancement for treating severe blepharoptosis. A retrospective study included 44 patients (60 eyelids) with severe ptosis who underwent the modified technique. Preoperatively, levator muscle function and margin reflex distance 1 (MRD1) were measured. Surgical outcomes, symmetry results and complications were evaluated postoperatively. At the 12-18 months follow-up, adequate or normal correction was achieved in 56 eyelids (93.3%), and 37 patients (84.1%) presented good or fair symmetry results. The most common complication was conjunctival prolapse, which was observed in six eyelids (10.0%), followed by lid fold deformity and under-correction. No exposure keratitis was recorded. In conclusion, the modified technique can physically elevate the eyelid with limited tissue injury and is effective for the correction of severe ptosis. Both satisfactory functional and esthetic results were achieved, and severe complications (such as exposure keratitis) were not observed.
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Affiliation(s)
- Yucheng Qiu
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Rui Jin
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xue Dong
- Department of Plastic and Reconstructive Surgery, The First Hospital of Jilin University, Changchun, China
| | - Yirui Shen
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Feixue Ding
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zhizhong Deng
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xianyu Zhou
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Youcong Ning
- The First People's Hospital of the Lancang Lahu Autonomous County, Yunnan, China
| | - Jun Yang
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Fei Liu
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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Jordan DR, Klapper SR, Farmer J. Oculopharyngeal Muscular Dystrophy Ptosis, Mueller's Muscle Involvement, and a Review of Management Over 34 Years. Ophthalmic Plast Reconstr Surg 2022; 38:535-542. [PMID: 35030153 DOI: 10.1097/iop.0000000000002118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To review the management of the ptosis associated with oculopharyngeal muscular dystrophy (OPMD) from one author's experience over 34 years, demonstrate Mueller's muscle involvement in this disease, and how this impacts the preferred choice of surgery. METHODS Retrospective, nonrandomized comparative case series. Forty patients with OPMD who underwent primary bilateral ptosis surgery through an anterior eyelid incision and had their Mueller's muscle biopsied (one side) and sent for histopathologic analysis were selected for chart review. The main outcome measure was the presence or absence of dystrophic changes in the biopsied Mueller's muscle. RESULTS In 29/40 biopsies (72.5%), there were dystrophic changes and fatty infiltration of Mueller's muscle identified histopathologically. CONCLUSIONS Mueller's muscle is involved in the dystrophic process more often than expected contributing to ptosis in the OPMD syndrome. A combined Mueller's-aponeurotic advancement is more effective at elevating the eyelid than simply advancing the aponeurosis when Mueller's is fatty infiltrated at the time of external levator advancement surgery in our experience. Management strategies for ptosis surgery in OPMD are reviewed. The age of onset, levator muscle function, previous ptosis repair, how debilitated the patient is with their disease process systemically, as well as the presence of other eye problems (e.g., dry eye, prior glaucoma filtering procedures, history of corneal surgery, laser refractive procedure) are important clinical considerations in patients with OPMD.
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Affiliation(s)
- David R Jordan
- Department of Ophthalmology, The Ottawa Hospital General Campus, Ottawa, Ontario, Canada
| | - Stephen R Klapper
- Department of Ophthalmology, Indiana University School of medicine, Indianapolis, Indiana, U.S.A
| | - James Farmer
- Department of Pathology, The Ottawa Hospital General Campus, Ottawa, Ontario, Canada
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Alonso-Pérez J, de León Hernández JC, Pérez-Pérez H, Mendoza-Grimón MD, Gutierrez-Martinez AJ, Hadjigeorgiou I, Montón-Álvarez F, González-Quereda L, Alonso-Jimenez A, Suárez-Calvet X, Díaz-Manera J. Clinical and genetic features of a large homogeneous cohort of oculopharyngeal muscular dystrophy patients from the Canary Islands. Eur J Neurol 2022; 29:1488-1495. [PMID: 35112761 DOI: 10.1111/ene.15252] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/30/2021] [Accepted: 01/10/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Oculopharyngeal muscular dystrophy (OPMD) is an autosomal dominant, late-onset myopathy characterized by ptosis, dysphagia, and progressive proximal limb muscle weakness. The disease is produced by a short expansion of the (GCN)n triplet in the PABPN1 gene. The size of expansion has been correlated to the disease onset and severity. We report the clinical features of a large cohort of OPMD patients harboring the (GCN)15 allele from the Canary Islands. METHODS A retrospective observational study was performed analyzing the clinical, demographic, and genetic data of 123 OPMD patients. Clinical data from this cohort were compared with clinical data collected in a large European study including 139 OPMD patients. RESULTS A total of 113 patients (94.2%) carried the (GCN)15 expanded PABN1 allele. Age of symptoms' onset was 45.1 years. The most frequent symptom at onset was ptosis (85.2%) followed by dysphagia (12%). The severity of the disease was milder in the Canary cohort compared to European patients as limb weakness (35.1% vs. 50.4%), the proportion of patients that require assistance for walking or use a wheelchair (9.3% vs. 27.4%), and needed of surgery because of severe dysphagia (4.6% vs. 22.8%) was higher in the European cohort. CONCLUSIONS Nearly 95% of patients with OPMD from the Canary Islands harbored the (GCN)15 expanded allele supporting a potential founder effect. Disease progression seemed to be milder in the (GCN)15 OPMD Canary cohort than in other cohorts with shorter expansions suggesting that other factors, apart from the expansion size, could be involved in the progression of the disease.
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Affiliation(s)
- Jorge Alonso-Pérez
- Neuromuscular Diseases Unit, Department of Neurology, Department of Medicine, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.,Department of Neurology, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, Spain
| | | | - Helena Pérez-Pérez
- Department of Neurology, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - María Dolores Mendoza-Grimón
- Department of Neurology, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | | | | | - Fernando Montón-Álvarez
- Department of Neurology, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, Spain
| | - Lidia González-Quereda
- Genetics Department, IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Valencia, Spain
| | - Alicia Alonso-Jimenez
- Neuromuscular Reference Center, Department of Neurology, Antwerp University Hospital, Antwerp, Belgium
| | - Xavier Suárez-Calvet
- Neuromuscular Diseases Unit, Department of Neurology, Department of Medicine, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Valencia, Spain
| | - Jordi Díaz-Manera
- Neuromuscular Diseases Unit, Department of Neurology, Department of Medicine, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Valencia, Spain.,John Walton Muscular Dystrophy Research Centre, Newcastle University and Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Long-term Results of Palpebral Fissure Transfer With No Lower Eyelid Spacer in Chronic Progressive External Ophthalmoplegia. Am J Ophthalmol 2022; 234:99-107. [PMID: 34339660 DOI: 10.1016/j.ajo.2021.07.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 07/09/2021] [Accepted: 07/22/2021] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the long-term outcomes of the palpebral fissure transfer (PFT) technique without lower eyelid spacer in patients with chronic progressive external ophthalmoplegia (CPEO). DESIGN Retrospective interventional case series. METHODS Consecutive patients with CPEO with PFT surgery (2006-2017) and a minimum follow-up of 24 months were included. The PFT included simultaneous levator resection or frontalis sling (based on the levator function and Bell's phenomenon) and lower eyelid retractor recession without spacer. Primary outcome measures included the change in margin reflex distance 1 (MRD-1), MRD-2, and palpebral fissure height (PFH) in the course of time. Potential predictors of keratopathy were also explored. RESULTS There were 32 patients (64 eyelids) with the mean age and follow-up of 34.1 years (range 15-56 years) and 37.9 months (range 24-72 months), respectively. Mean MRD-1 significantly increased from -0.9 mm to 3.4 mm in postoperative weeks 1 and 2 and 1.8 mm at the last follow-up. Mean MRD-2 significantly decreased from 5.6 mm to 3.7 mm in postoperative weeks 1 and 2 and 5 mm at the last follow-up. Eyes with frank lower eyelid retraction (MRD-2 >5 mm) gained more reduction in MRD-2 compared with those with no sclera show (-0.9 mm vs -0.3 mm, P < .001). Reoperation was performed in 9 eyelids for under- (n = 5) and overcorrection (n = 4). Persistent keratopathy was observed in 3 eyes (4.5%). CONCLUSION Lower eyelid retractor recession without spacer yields significant protective corneal coverage at the critical early postoperative period when the risk of keratopathy is highest.
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Tian G, Sun X, Qian J. Extraocular Muscle Disorders. Neuroophthalmology 2022. [DOI: 10.1007/978-981-19-4668-4_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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10
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Costa RHA, Castro ÁBBSD, Silva SDCE, Léda RM, Amorim RFBD. Comparação da fáscia lata, faixa de silicone e fio de polipropileno na cirurgia de suspensão frontal para correção de ptose palpebral grave. REVISTA BRASILEIRA DE OFTALMOLOGIA 2021. [DOI: 10.37039/1982.8551.20210055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Safety and Efficacy of the Under-Corrected Frontalis Sling in Myogenic Ptosis Accompanying Extraocular Muscle Paralysis. J Craniofac Surg 2020; 31:e802-e805. [PMID: 33136917 DOI: 10.1097/scs.0000000000006759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Eshaghi M, Arabi A, Eshaghi S. Surgical management of ptosis in chronic progressive external ophthalmoplegia. Eur J Ophthalmol 2020; 31:2064-2068. [PMID: 32847396 DOI: 10.1177/1120672120952344] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To determine possible complications and efficacy of ptosis surgery in a series of chronic progressive external ophthalmoplegia (CPEO) patients with healthy tear film. METHOD It is a prospective interventional study on 24 eyes from 12 patients with the diagnosis of CPEO and ptosis. Pre-operatively, tear breakup test (TBUT) and Schirmer test were performed to assess lacrimal function unit. Levator resection was performed for 16 eyes with levator function (LF) more than 4 mm, while eight eyes from four patients with poorer LF underwent frontalis silicone sling surgery. Main outcome measures included change in marginal-to-reflex distance (MRD1) and incidence of post-operative exposure keratopathy. RESULTS The mean age of the patients was 45 ± 15 years. The mean of TBUT and Schirmer test were 12 ± 1.98 s and 15 ± 2.76 mm, respectively. The mean follow-up period was 34 months. Four eyes encountered mild to moderate exposure keratopathy. All cases were managed medically, with no need for surgical revision. The mean pre-operative MRD1, LF, and chin-up angle were -0.54 ± 1.03 mm, 4.21 ± 1.41 mm, and 21.6 ± 6.01 degrees, respectively. The mean post-operative MRD1, LF, and chin-up angle were 2.42 ± 0.60, 4.46 ± 1.53 mm, and 3.3 ± 1.01 degrees, respectively. At 1-year follow-up visit, improvement in MRD1 and chin-up posture was statistically significant (p-value < 0.05). CONCLUSION Normal TBUT and Schirmer test results, prophylactic lubricating therapy, and close follow-up can be as important as Bell's phenomenon and palpebral fissure height in predicting post-operative complications.
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Affiliation(s)
- Mohammad Eshaghi
- Ophthalmology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Arabi
- Ophthalmic Research Center, Torfe Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sarvin Eshaghi
- Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Affiliation(s)
- Ema Avdagic
- Department of Ophthalmology and Visual Science, University of Chicago, Chicago, IL, United States
| | - Paul O Phelps
- Department of Ophthalmology and Visual Science, University of Chicago, Chicago, IL, United States; Department of Surgery, Northshore University HealthSystem, 2050 Pfingsten Rd., Ste. 280, Glenview, Evanston, IL 60026, United States.
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14
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Unilateral Frontalis Suspension With Silicone Sling Without Levator Extirpation in Congenital Ptosis With Marcus Gunn Jaw Winking Synkinesis. Ophthalmic Plast Reconstr Surg 2019; 36:390-394. [PMID: 31880686 DOI: 10.1097/iop.0000000000001566] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE To evaluate the efficacy of unilateral tarso-frontalis silicone sling without levator extirpation or disinsertion in dampening the jaw wink in patients with congenital ptosis associated with Marcus Gunn Jaw Winking synkinesis phenomenon. METHODS Retrospective review of medical records of all patients of congenital ptosis with moderate to severe Marcus Gunn jaw winking synkinesis who underwent unilateral tarsofrontal silicone sling surgery without extirpation of the levator muscle were retrospectively reviewed. Data were collected about the pre- and the postoperative severity of the ptosis and the amount of Marcus Gunn jaw winking excursion. RESULTS Twenty-three patients were included in the study. Mean postoperative follow up duration was 31.2 (range 6-208) weeks. The severity of the preoperative jaw wink was mild (<2 mm excursion) in 0 patient, moderate (2-5mm) in 15 (65%) patients, and severe (>5 mm eyelid excursion) in 8 (35%) patients. Postoperatively, 20 (87%) patients had mild residual jaw wink, 3 (13%) patients had moderate jaw wink and none of the patient had severe residual jaw wink. CONCLUSION Unilateral tarsofrontal silicone sling without disinsertion or extirpation of the levator can reduce the severity of the jaw wink excursion in patients with congenital ptosis with moderate to severe preoperative Marcus Gunn jaw winking synkinesis.
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Frontalis Linkage Without Intraoperative Eyelid Elevation for the Management of Myopathic Ptosis. Ophthalmic Plast Reconstr Surg 2019; 36:258-262. [PMID: 31809486 DOI: 10.1097/iop.0000000000001525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To report the effect of frontalis linkage without intraoperative eyelid elevation for the management of myopathic ptosis. METHODS Retrospective analysis of 21 (42 eyelids) myopathic patients with bilateral ptosis who were operated between 1999 and 2017. All patients had orbicularis weakness and poor or absent Bell's phenomenon. Surgery consisted of using an autogenous fascia sling to link the tarsal plate to the frontalis muscle without any degree of intraoperative eyelid elevation. The main outcome measures were margin reflex distance, brow height and degree of brow excursion and degree of lagophthalmos, and exposure keratitis. RESULTS After surgery, there were significant changes (p <0.0001) in both margin reflex distance and brow position. Mean margin reflex distance increased to 1.4 mm ± 1.34 DP and with full frontalis contraction, it reached 3.0 mm ± 1.73 DP, while mean brow position decreased 1.6 mm ± 1.59 SD, p < 0.0001. Postoperative lagophthalmos was not detected in 31 (74%) eyes. In the remaining 11 eyes (26%), lagophthalmos ranged from 1.2 to 5.2 mm (mean = 1.7 mm ± 0.74 DP). Mild inferior superficial keratitis was detected in 14 eyes (33.3%) of 7 patients only 3 of which had lagophthalmos. One patient needed additional surgery to correct unilateral eyelid retraction. Overall, 81.81% of the patients were pleased with the procedure. CONCLUSIONS Myopathic ptosis can be alleviated with a minimal amount of lagophthalmos by just linking the tarsal plate to the frontalis muscle without lifting the eyelid margin intraoperatively.
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16
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Mitochondrial disorders and the eye. Surv Ophthalmol 2019; 65:294-311. [PMID: 31783046 DOI: 10.1016/j.survophthal.2019.11.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 11/16/2019] [Accepted: 11/18/2019] [Indexed: 01/27/2023]
Abstract
Mitochondria are cellular organelles that play a key role in energy metabolism and oxidative phosphorylation. Malfunctioning of mitochondria has been implicated as the cause of many disorders with variable inheritance, heterogeneity of systems involved, and varied phenotype. Metabolically active tissues are more likely to be affected, causing an anatomic and physiologic disconnect in the treating physicians' mind between presentation and underlying pathophysiology. We shall focus on disorders of mitochondrial metabolism relevant to an ophthalmologist. These disorders can affect all parts of the visual pathway (crystalline lens, extraocular muscles, retina, optic nerve, and retrochiasm). After the introduction reviewing mitochondrial structure and function, each disorder is reviewed in detail, including approaches to its diagnosis and most current management guidelines.
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Kurtz NS, Cote C, Heatwole C, Gagnon C, Youssof S. Patient-reported disease burden in oculopharyngeal muscular dystrophy. Muscle Nerve 2019; 60:724-731. [PMID: 31531865 DOI: 10.1002/mus.26712] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 09/09/2019] [Accepted: 09/11/2019] [Indexed: 01/10/2023]
Abstract
INTRODUCTION There is currently little evidence regarding oculopharyngeal muscular dystrophy (OPMD) disease burden reported by patients. In this study we aim to elicit direct patient input regarding OPMD disease burden. METHODS We conducted semistructured interviews with 25 participants with genetically confirmed OPMD and a wide range of disease duration (15 ± 8 years). Using the Framework Technique, themes and categories were then extracted. RESULTS Analyses revealed 7 themes (physical impact, mental impact, social impact, perception of progression, treatment perceptions, coping strategies, and access to disease information), encompassing 27 categories of OPMD disease burden. The most frequent categories were related to dysphagia, coping strategies for dysphagia, and impaired mobility. DISCUSSION This study demonstrates the importance of considering, when providing clinical care, the broad range of coping strategies patients use to deal with OPMD symptoms, especially dysphagia, to properly assess limitations and monitor real disease progression.
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Affiliation(s)
- Nicolette S Kurtz
- Department of Neurology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Claudia Cote
- Centre de recherche Charles-Le Moyne-Saguenay-Lac-Saint-Jean sur les innovations en santé, Sherbrooke University, Sherbrooke, Québec, Canada
| | - Chad Heatwole
- Department of Neurology, University of Rochester, Rochester, New York
| | - Cynthia Gagnon
- Centre de recherche Charles-Le Moyne-Saguenay-Lac-Saint-Jean sur les innovations en santé, Sherbrooke University, Sherbrooke, Québec, Canada
| | - Sarah Youssof
- Department of Neurology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
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Lee CC, Feng IJ, Lai HT, Huang SH, Kuo YR, Lai CS. The Epidemiology and Clinical Features of Blepharoptosis in Taiwanese Population. Aesthetic Plast Surg 2019; 43:964-972. [PMID: 30877447 DOI: 10.1007/s00266-019-01344-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 02/21/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Blepharoptosis describes a condition of low-lying upper eyelid that may affect individuals of all ages under various etiologies. It may be of congenital or acquired form by the timing of onset or be divided into myogenic, neurogenic, aponeurotic, or mechanical types according to the mechanism. Our goal was to report the characteristics of age-specific blepharoptosis and to analyze the association between levator function (LF) and ptosis severity of each ptosis subtype. MATERIALS AND METHODS The retrospective, single-center, cross-sectional study consisted of patients diagnosed with blepharoptosis in the plastic surgery practice at a medical center between September 2009 and May 2017. We reported patients' age at presentation, sex, laterality of ptosis, etiology, classification, and evaluation of ptosis including levator function and ptosis severity. RESULTS During a nine-year span of study, a total of 1975 eyelids of 1164 Taiwanese patients aged between 2 and 88 years were enrolled in the research (mean = 57.73 ± 13.41 years). The female-to-male ratio was 2.72 (95% confidence interval [CI]: p < 0.0001). Acquired blepharoptosis and bilateral blepharoptosis were more frequently observed (55.85%, p < 0.0001 and 69.67%, p < 0.0001, respectively). In age-specific relative incidence of blepharoptosis, myogenic ptosis was the majority in patients younger than 40 years. Early onset of aponeurotic ptosis was observed in young contact lenses wearers. Aponeurotic blepharoptosis was the predominant type of ptosis in the senior population older than 40 years (p < 0.0001). Among the subtypes, mechanical ptosis had the most preserved LF (p < 0.0001). LF and MRD1 had statistically positive correlations in all subtypes of blepharoptosis, in which neurogenic ptosis demonstrated the severest levator dysfunction for each millimeter in MRD1 reduction. CONCLUSIONS Of the 1164 Taiwanese patients, blepharoptosis had a higher propensity for female gender and the age between the second to fourth decades. Bilateral involvement of blepharoptosis with acquired type was frequently diagnosed. Myogenic ptosis had a preponderance in age younger than 40 years, while aponeurotic ptosis usually affects senile population. Many mild degree myogenic ptosis was simultaneously recognized in young-aged adults seeking aesthetic double eyelid surgery. Early onset of acquired aponeurotic ptosis was also observed in contact lens wearers given the trend of decorative contact lens use. Levator dysfunction was implicated in the pathology of not only myogenic ptosis but aponeurotic, mechanical, and neurogenic ptosis. Moreover, levator function of neurogenic ptosis was most severely impacted in each MRD1 reduction among all subtypes of blepharoptosis. 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 .
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Affiliation(s)
- Chia-Chen Lee
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - I-Jung Feng
- Department of Healthcare Administration and Medical Informatics, Chi-Mei Medical Center, Tainan, Taiwan
| | - Hsin-Ti Lai
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, No.100, Tzyou 1st Rd, Kaohsiung, 807, Taiwan
| | - Shu-Hung Huang
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, No.100, Tzyou 1st Rd, Kaohsiung, 807, Taiwan
| | - Yur-Ren Kuo
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, No.100, Tzyou 1st Rd, Kaohsiung, 807, Taiwan
| | - Chung-Sheng Lai
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, No.100, Tzyou 1st Rd, Kaohsiung, 807, Taiwan.
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Alonso-Jimenez A, Kroon RHMJM, Alejaldre-Monforte A, Nuñez-Peralta C, Horlings CGC, van Engelen BGM, Olivé M, González L, Verges-Gil E, Paradas C, Márquez C, Garibaldi M, Gallano P, Rodriguez MJ, Gonzalez-Quereda L, Dominguez Gonzalez C, Vissing J, Fornander F, Eisum ASV, García-Sobrino T, Pardo J, García-Figueiras R, Muelas N, Vilchez JJ, Kapetanovic S, Tasca G, Monforte M, Ricci E, Gomez MT, Bevilacqua JA, Diaz-Jara J, Zamorano II, Carlier RY, Laforet P, Pelayo-Negro A, Ramos-Fransi A, Martínez A, Marini-Bettolo C, Straub V, Gutiérrez G, Stojkovic T, Martín MA, Morís G, Fernández-Torrón R, Lopez De Munaín A, Cortes-Vicente E, Querol L, Rojas-García R, Illa I, Diaz-Manera J. Muscle MRI in a large cohort of patients with oculopharyngeal muscular dystrophy. J Neurol Neurosurg Psychiatry 2019; 90:576-585. [PMID: 30530568 DOI: 10.1136/jnnp-2018-319578] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/13/2018] [Accepted: 11/19/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVE Oculopharyngeal muscular dystrophy (OPMD) is a genetic disorder caused by an abnormal expansion of GCN triplets within the PABPN1 gene. Previous descriptions have focused on lower limb muscles in small cohorts of patients with OPMD, but larger imaging studies have not been performed. Previous imaging studies have been too small to be able to correlate imaging findings to genetic and clinical data. METHODS We present cross-sectional, T1-weighted muscle MRI and CT-scan data from 168 patients with genetically confirmed OPMD. We have analysed the pattern of muscle involvement in the disease using hierarchical analysis and presented it as heatmaps. Results of the scans were correlated with genetic and clinical data. RESULTS Fatty replacement was identified in 96.7% of all symptomatic patients. The tongue, the adductor magnus and the soleus were the most commonly affected muscles. Muscle pathology on MRI correlated positively with disease duration and functional impairment. CONCLUSIONS We have described a pattern that can be considered characteristic of OPMD. An early combination of fat replacement in the tongue, adductor magnus and soleus can be helpful for differential diagnosis. The findings suggest the natural history of the disease from a radiological point of view. The information generated by this study is of high diagnostic value and important for clinical trial development.
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Affiliation(s)
- Alicia Alonso-Jimenez
- Neuromuscular Disorders Unit, Neurology Department, Hospital de la Santa Creu I Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | | | | | | | - Corinne G C Horlings
- Neurology Department, Radboud university Medical Center, Nijmegen, The Netherlands
| | | | - Montse Olivé
- Pathology Department (Neuropathology), Neuromuscular Disorders Unit, IDIBELL, Hospital de Bellvitge, Barcelona, Spain
| | - Laura González
- Pathology Department (Neuropathology), Neuromuscular Disorders Unit, IDIBELL, Hospital de Bellvitge, Barcelona, Spain
| | - Enric Verges-Gil
- Pathology Department (Neuropathology), Neuromuscular Disorders Unit, IDIBELL, Hospital de Bellvitge, Barcelona, Spain
| | - Carmen Paradas
- Neuromuscular Disorders Unit, Neurology Department, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, Sevilla, Spain
| | - Celedonio Márquez
- Neuromuscular Disorders Unit, Neurology Department, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, Sevilla, Spain
| | - Matteo Garibaldi
- Neuromuscular Disorders Unit, Department of Neurology, Mental Health and Sensory Organs (NESMOS), SAPIENZA University of Rome, Ospedale Sant'Andrea, Rome, Italy
| | - Pía Gallano
- Genetic Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Valencia, Spain
| | | | - Lidia Gonzalez-Quereda
- Genetic Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Valencia, Spain
| | - Cristina Dominguez Gonzalez
- Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Valencia, Spain.,Neuromuscular Disorders Unit, Neurology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - John Vissing
- Copenhagen Neuromuscular Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Freja Fornander
- Copenhagen Neuromuscular Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anne-Sofie Vibæk Eisum
- Copenhagen Neuromuscular Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Julio Pardo
- Neurology Department, Hospital Clínico, Santiago de Compostela, Spain
| | | | - Nuria Muelas
- Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Valencia, Spain.,Neuromuscular Research Unit, Neurology Department, Instituto de Investigación Sanitaria la Fe, Hospital Universitari i Politécnic La Fe, Valencia, Spain
| | - Juan Jesús Vilchez
- Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Valencia, Spain.,Neuromuscular Research Unit, Neurology Department, Instituto de Investigación Sanitaria la Fe, Hospital Universitari i Politécnic La Fe, Valencia, Spain
| | | | - Giorgio Tasca
- Unità Operativa Complessa di Neurologia, Fondazione Policlinico Universitario A, Gemelli IRCCS, Roem, Italy
| | - Mauro Monforte
- Unità Operativa Complessa di Neurologia, Fondazione Policlinico Universitario A, Gemelli IRCCS, Roem, Italy.,Istituto di Neurologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Enzo Ricci
- Unità Operativa Complessa di Neurologia, Fondazione Policlinico Universitario A, Gemelli IRCCS, Roem, Italy.,Istituto di Neurologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - María Teresa Gomez
- Neurology Department, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Jorge Alfredo Bevilacqua
- Departamento de Neurología y Neurocirugía, Hospital Clínico Universidad de Chile, Programa de Anatomía y Medicina Legal, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Jorge Diaz-Jara
- Centro de imagenología, Hospital Clínico Universidad de Chile, Universidad de Chile, Santiago, Chile
| | - Ivonne Ingrid Zamorano
- Servicio de Neurología, Hospital de Puerto Montt, Servicio de Salud del Reloncavi, Los Lagos Region, Chile
| | - Robert Yves Carlier
- Assistance Publique des Hôpitaux de Paris (AP-HP), Service d'Imagerie Médicale, Pôle Neuro-locomoteur, Hôpital Raymond Poincaré, Garches, Hôpitaux Universitaires Paris-Ile-de-France Ouest, Garches, France
| | - Pascal Laforet
- Assistance Publique des Hôpitaux de Paris (AP-HP), Service de neurologie, Pôle Neuro-locomoteur, Hôpital Raymond Poincaré, Garches, Hôpitaux Universitaires Paris-Ile-de-France Ouest, Garches, France
| | - Ana Pelayo-Negro
- Neurology Department, University Hospital "Marqués de Valdecilla (IDIVAL)", University of Cantabria, and "Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED)", Santander, Spain
| | - Alba Ramos-Fransi
- Neurology Department, Hospital Germans Trias I Pujol, Barcelona, Spain
| | | | - Chiara Marini-Bettolo
- The John Walton Muscular Dystrophy Research Centre, MRC Centre for Neuromuscular Diseases Institute of Genetic Medicine, University of Newcastle, Newcastle upon Tyne, UK
| | - Volker Straub
- The John Walton Muscular Dystrophy Research Centre, MRC Centre for Neuromuscular Diseases Institute of Genetic Medicine, University of Newcastle, Newcastle upon Tyne, UK
| | - Gerardo Gutiérrez
- Neurology Department, Hospital Infanta Sofía, San Sebastián de los Reyes, Spain
| | - Tanya Stojkovic
- Institute of Myology, Pitié-Salpêtrière Hospital, Paris, France
| | | | - Germán Morís
- Neurology Department, Hospital Universitario Central de Asturias, Asturias, Spain
| | - Roberto Fernández-Torrón
- Neurology Department, Hospital Donostia, San Sebastián, Spain.,Neuromuscular Area, Neurology Service, Biodonostia Health Research Institute, Donostia University Hospital, Donostia-San Sebastián, Spain
| | - Adolfo Lopez De Munaín
- Neurology Department, Hospital Donostia, San Sebastián, Spain.,Neuromuscular Area, Neurology Service, Biodonostia Health Research Institute, Donostia University Hospital, Donostia-San Sebastián, Spain
| | - Elena Cortes-Vicente
- Neuromuscular Disorders Unit, Neurology Department, Hospital de la Santa Creu I Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Valencia, Spain
| | - Luis Querol
- Neuromuscular Disorders Unit, Neurology Department, Hospital de la Santa Creu I Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Valencia, Spain
| | - Ricardo Rojas-García
- Neuromuscular Disorders Unit, Neurology Department, Hospital de la Santa Creu I Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Valencia, Spain
| | - Isabel Illa
- Neuromuscular Disorders Unit, Neurology Department, Hospital de la Santa Creu I Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Valencia, Spain
| | - Jordi Diaz-Manera
- Neuromuscular Disorders Unit, Neurology Department, Hospital de la Santa Creu I Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain .,Centro de Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Valencia, Spain
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Comparison of Revision Rates of Anterior- and Posterior-Approach Ptosis Surgery: A Retrospective Review of 1519 Cases. Ophthalmic Plast Reconstr Surg 2018; 34:246-253. [PMID: 28582369 DOI: 10.1097/iop.0000000000000938] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare revision rates for ptosis surgery between posterior-approach and anterior-approach ptosis repair techniques. METHODS This is the retrospective, consecutive cohort study. All patients undergoing ptosis surgery at a high-volume oculofacial plastic surgery practice over a 4-year period. A retrospective chart review was conducted of all patients undergoing posterior-approach and anterior-approach ptosis surgery for all etiologies of ptosis between 2011 and 2014. Etiology of ptosis, concurrent oculofacial surgeries, revision, and complications were analyzed. The main outcome measure is the ptosis revision rate. RESULTS A total of 1519 patients were included in this study. The mean age was 63 ± 15.4 years. A total of 1056 (70%) of patients were female, 1451 (95%) had involutional ptosis, and 1129 (74.3%) had concurrent upper blepharoplasty. Five hundred thirteen (33.8%) underwent posterior-approach ptosis repair, and 1006 (66.2%) underwent anterior-approach ptosis repair. The degree of ptosis was greater in the anterior-approach ptosis repair group. The overall revision rate for all patients was 8.7%. Of the posterior group, 6.8% required ptosis revision; of the anterior group, 9.5% required revision surgery. The main reason for ptosis revision surgery was undercorrection of one or both eyelids. Concurrent brow lifting was associated with a decreased, but not statistically significant, rate of revision surgery. Patients who underwent unilateral ptosis surgery had a 5.1% rate of Hering's phenomenon requiring ptosis repair in the contralateral eyelid. Multivariable logistic regression for predictive factors show that, when adjusted for gender and concurrent blepharoplasty, the revision rate in anterior-approach ptosis surgery is higher than posterior-approach ptosis surgery (odds ratio = 2.08; p = 0.002). CONCLUSIONS The overall revision rate in patients undergoing ptosis repair via posterior-approach or anterior-approach techniques is 8.7%. There is a statistically higher rate of revision with anterior-approach ptosis repair.
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Abstract
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.
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Affiliation(s)
- Ju-Hyang Lee
- Department of Ophthalmology, Ulsan University Hospital, Ulsan University School of Medicine, Ulsan, Korea
| | - Yoon-Duck Kim
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Tarsal switch using an anterior approach to correct severe ptosis. Arch Plast Surg 2018; 45:165-170. [PMID: 29566467 PMCID: PMC5869425 DOI: 10.5999/aps.2017.00465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 02/02/2018] [Accepted: 02/28/2018] [Indexed: 11/08/2022] Open
Abstract
Background To present the outcomes of the tarsal switch procedure using an anterior approach to correct severe ptosis with poor levator muscle function (<4 mm) with absent or poor Bell’s phenomenon. Methods This retrospective case series included 11 patients with severe neurogenic or acquired myogenic palpebral ptosis. All patients underwent the tarsal switch procedure through an anterior approach from 2012 to 2015. Margin reflex distance (MRD1 and MRD2) and the palpebral fissure were evaluated preoperatively and postoperatively. Data were compared using the Wilcoxon signed-rank test. P-values <0.05 were considered to indicate statistical significance. Results Surgery was performed on 18 eyelids (11 patients). The median age at surgery was 57 years (range, 29-86 years). Four patients had unilateral ptosis and seven had bilateral ptosis. Nine patients had myogenic ptosis and two had neurogenic ptosis. Postoperatively, the chin-up position improved in all patients. The MRD1 increased statistically significantly, from 0 mm preoperatively to 1.0 mm postoperatively (P=0.001). The MRD2 decreased statistically significantly, from 4.5 mm preoperatively to 3.0 mm postoperatively (P=0.001). The palpebral fissure did not change (4.0 mm preoperatively to 4.0 mm postoperatively) (P=0.13). Conclusions The tarsal switch procedure through an anterior approach is an effective alternative for correcting severe ptosis, especially neurogenic or acquired myogenic ptosis. This procedure can be performed with minimal risk of ocular surface exposure and provides stable outcomes.
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Hamama J, Khalfi L, Sabani H, El Khatib K. Frontalis suspension using autogenous temporal fascia by Fox technique. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2018; 119:311-314. [PMID: 29499365 DOI: 10.1016/j.jormas.2018.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 02/05/2018] [Accepted: 02/21/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Severe ptosis of more than 4mm with poor levator function of less than 4mm is treated via the frontalis muscle suspension technique using autogenous temporal fascia. TECHNICAL NOTE The surgery was performed under general anaesthesia. The eyelid crease was incised and the tarsus exposed. An incision centered on the mid-pupillary level was then made just above the eyebrow with exposure of the frontalis muscle. The temporal fascia strip was sutured to the tarsus at three points. Every free end of the strip was then slid through the adjacent forehead subcutaneous tunnel to emerge together through the medial forehead incision. The eyelid crease was re-formed by suturing the skin with the graft. DISCUSSION Frontalis suspension using autologous material is a harmless procedure, which does not alter the upper eyelid structures. It is an effective procedure in the long-term.
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Affiliation(s)
- J Hamama
- Department of Oral and Facial Surgery, Mohammed V Teaching Armed Forces Hospital, BP, 10100 Rabat, Morocco; Faculty of Medicine and Pharmacy, University Mohammed V, Rabat 6203, Morocco.
| | - L Khalfi
- Department of Oral and Facial Surgery, Mohammed V Teaching Armed Forces Hospital, BP, 10100 Rabat, Morocco; Faculty of Medicine and Pharmacy, University Sidimohammed Ben Abdellah, Fes 1893, Morocco
| | - H Sabani
- Department of Oral and Facial Surgery, Mohammed V Teaching Armed Forces Hospital, BP, 10100 Rabat, Morocco; Faculty of Medicine and Pharmacy, University Hassan II, Casablanca 9167, Morocco
| | - K El Khatib
- Department of Oral and Facial Surgery, Mohammed V Teaching Armed Forces Hospital, BP, 10100 Rabat, Morocco; Faculty of Medicine and Pharmacy, University Mohammed V, Rabat 6203, Morocco
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Cruz-Aguilar M, Guerrero-de Ferran C, Tovilla-Canales JL, Nava-Castañeda A, Zenteno JC. Characterization of PABPN1 expansion mutations in a large cohort of Mexican patients with oculopharyngeal muscular dystrophy (OPMD). J Investig Med 2016; 65:705-708. [PMID: 27980005 DOI: 10.1136/jim-2016-000184] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2016] [Indexed: 11/03/2022]
Abstract
Oculopharyngeal muscular dystrophy (OPMD) is an autosomal-dominant, adult-onset disorder defined by blepharoptosis, dysphagia, and proximal muscle weakness. OPMD arises from heterozygous expansions of a trinucleotide (GCN) tract situated at the 5' region of the polyadenylate RNA binding protein 1 (PABPN1) gene. The frequency of a particular (GCN) expansion in a given population of patients with OPMD is largely influenced by the occurrence of founder mutations. Analysis of large groups of patients with OPMD from different ethnic origins will help to estimate the relative contribution of each expanded allele to the disease. The purpose of this study was to characterize the type of PABPN1 expanded alleles in a large cohort of OPMD individuals from Mexico. Molecular analysis procedures included genomic DNA extraction from blood leukocytes in each patient followed by PCR amplification of PABPN1 exon 1, and direct nucleotide sequencing of PCR products. A total of 102 patients with OPMD were included in the study. Expanded PABPN1 gene alleles were demonstrated in all patients: 65% (66 out of 102) had a (GCN)15 expansion while the remaining 35% (36 out of 102) exhibited a (GCN)13 expansion. This is one of the largest series of molecularly confirmed patients with OPMD in a non-Caucasian population. Ethnic-specific differences in the prevalence of specific PABPN1 expansions must be considered for genetic screening of patients with OPMD.
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Affiliation(s)
- Marisa Cruz-Aguilar
- Department of Genetics-Research Unit, Institute of Ophthalmology "Conde de Valenciana", Mexico City, Mexico
| | | | | | - Angel Nava-Castañeda
- Department of Oculoplastics, Institute of Ophthalmology "Conde de Valenciana", Mexico City, Mexico
| | - Juan C Zenteno
- Department of Genetics-Research Unit, Institute of Ophthalmology "Conde de Valenciana", Mexico City, Mexico.,Faculty of Medicine, Department of Biochemistry, UNAM, Mexico City, Mexico
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Vemuri S, Christianson MD, Demirci H. Correcting myogenic ptosis accompanying extraocular muscle weakness: The "Bobby Pin" procedure. Orbit 2016; 35:267-270. [PMID: 27541941 DOI: 10.1080/01676830.2016.1193528] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 05/20/2016] [Indexed: 06/06/2023]
Abstract
This article evaluates the "Bobby Pin" procedure in the correction of myogenic ptosis accompanying extraocular muscle weakness. We retrospectively reviewed 26 eyelids of 13 patients who underwent "Bobby Pin" procedure for myogenic ptosis accompanying extraocular muscle weakness. We evaluated the patients' clinical features such as age, etiology of ptosis, symptoms, standard ptosis measurements, associated systemic diseases, additional ophthalmic conditions, complications, and recurrence. Etiology of myogenic ptosis and extraocular muscle weakness was oculopharyngeal dystrophy in 4 (31%) patients, chronic progressive external ophthalmoplegia in 4 (31%) patients, myotonic dystrophy in 2 (23%) patients, and idiopathic in 3 (15%) patients. The mean levator function was approximately 5 mm pre- and post-operatively (range 1 to 12 mm). The mean margin-to-reflex distance 1 increased from -1.1 mm (below the light reflex) pre-operatively to +0.4 mm (above the light reflex) post-operatively. After a mean follow-up of 40 months, only 1 (8%) patient experienced ptosis recurrence. Upper eyelids were symmetric in both contour and height in all patients. Mild superficial keratopathy involving less than 10% of cornea was observed in 4 (31%) patients. The "Bobby Pin" procedure is an effective and long-lasting treatment option for correcting acquired ptosis accompanying extraocular muscle weakness. The procedure is safe, simple, easily learned, time- and cost-effective, and does not require any expensive equipment.
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Affiliation(s)
- Swapna Vemuri
- a Department of Ophthalmology , Henry Ford Hospital , Detroit , Michigan , USA
| | | | - Hakan Demirci
- b Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center , University of Michigan , Ann Arbor , Michigan , USA
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Comparison of Two Polypropylene Frontalis Suspension Techniques in 92 Patients With Oculopharyngeal Muscular Dystrophy. Ophthalmic Plast Reconstr Surg 2016; 33:57-60. [PMID: 26866330 DOI: 10.1097/iop.0000000000000648] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To compare the functional outcome of the polypropylene trapezoid frontalis suspension with the polypropylene modified Crawford frontalis suspension in a large cohort of patients with oculopharyngeal muscular dystrophy. METHODS Retrospective, nonrandomized comparative case series. Patients with oculopharyngeal muscular dystrophy who underwent bilateral polypropylene frontalis suspension were selected for chart review. Main outcome measures were margin reflex distance, duration of surgery, and ptosis recurrence. RESULTS Ninety-two patients qualified for chart review; 39 patients underwent the trapezoid sling and 53 patients the modified Crawford sling. There was no difference in preoperative margin reflex distance or levator function between the 2 surgical groups. Postoperative improvement in margin reflex distance was 2.95 ± 1.56 mm in the trapezoid group compared with 2.85 ± 1.65 mm in the modified Crawford group (p = 0.67). Duration of surgery was 40.49 ± 13.33 minutes in the trapezoid group compared with 53.77 ± 16.04 minutes in the modified Crawford group (p < 0.001). Five percent of eyes in the trapezoid group had ptosis recurrence compared with 13% of eyes in the modified Crawford group (p = 0.07). CONCLUSION Both polypropylene frontalis suspension techniques generated an equivalent increase in margin reflex distance. However, the trapezoid frontalis suspension required less operative time and trended toward a lower rate of ptosis recurrence.
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Choi SH, Yang HK, Hwang JM, Park KS. Ocular Findings of Myotonic Dystrophy Type 1 in the Korean Population. Graefes Arch Clin Exp Ophthalmol 2016; 254:1189-93. [DOI: 10.1007/s00417-016-3266-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 01/05/2016] [Accepted: 01/07/2016] [Indexed: 11/30/2022] Open
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Litwin AS, Patel B, McNab AA, McCann JD, Leatherbarrow B, Malhotra R. Blepharoptosis surgery in patients with myasthenia gravis. Br J Ophthalmol 2015; 99:899-902. [DOI: 10.1136/bjophthalmol-2014-306335] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 12/26/2014] [Indexed: 11/03/2022]
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Sebastiá R, Fallico E, Fallico M, Fortuna E, Lessa S, Neto GH. Bilateral lid/brow elevation procedure for severe ptosis in Kearns-Sayre syndrome, a mitochondrial cytopathy. Clin Ophthalmol 2014; 9:25-31. [PMID: 25565765 PMCID: PMC4278785 DOI: 10.2147/opth.s74179] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background The purpose of this work was to determine the effectiveness and possible complications encountered with bilateral fascia lata lid suspension used to correct blepharoptosis in patients with Kearns-Sayre syndrome. Methods This was a retrospective study of seven patients with Kearns-Sayre syndrome who had a minimum of 1 year of follow-up. A bilateral fascia lata sling was used to correct the ptosis. Preoperative and postoperative measurements of the vertical lid fissure width (VFW) and marginal reflex distance (MRD) were performed. The Student’s t-test was used to analyze the results. Results The mean preoperative VFW and MRD measurements were 4±2.45 mm and 0.14±0.92 mm, respectively. The mean postoperative VFW and MRD measurements were 7.71±1.85 mm, and 2.86±1.69 mm, respectively. All preoperative and postoperative values were considered to be statistically significant (P<0.01). Adequate elevation of the lids was obtained in all patients, both functionally and aesthetically. All of the patients showed a mild symmetric postoperative inferior version lagophthalmos, and one patient developed corneal ulceration and scarring due to corneal exposure and a weak Bell’s phenomenon. Conclusion The surgical technique described to correct the blepharoptosis found in patients with Kearns-Sayre syndrome was found to be efficient and relatively safe. The correction should be conservative to decrease the risk of postoperative corneal damage that occurred in one patient.
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Affiliation(s)
- Roberto Sebastiá
- Department of Ophthalmology, Fluminense Federal University, Niterói, Brazil ; Oculoplastic Surgery Department, 38th Infirmary of the Santa Casa de Misericordia do Rio de Janeiro, Instituto Ivo Pitanguy, Pontifícia Universidade Catolica do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ester Fallico
- Clinica Gretter, Università degli Studi di Catania, Catania, Italy
| | - Matteo Fallico
- Facoltà di Medicina e Chirurgia, Università degli Studi di Catania, Catania, Italy
| | - Eduardo Fortuna
- Hospital da Plástica, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Sergio Lessa
- Oculoplastic Surgery Department, 38th Infirmary of the Santa Casa de Misericordia do Rio de Janeiro, Instituto Ivo Pitanguy, Pontifícia Universidade Catolica do Rio de Janeiro, Rio de Janeiro, Brazil ; Post-Graduate Program in Physiopathology in Surgical Science, State University of Rio de Janeiro, Rio de Janeiro, Brazil
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Abstract
Background:Progressive external ophthalmoplegia (PEO) is a mitochondrial myopathy of ocular muscles. Diagnostic investigation usually involves limb skeletal muscle biopsy and molecular genetic studies, although diagnostic yield tends to be low. The purpose of this study was to evaluate the diagnostic yield obtained by analysis of levator palpebrae (LP) muscle tissue.Methods:This is a clinicopathologic study of 8 patients with a diagnosis of PEO, who had LP muscle biopsies as part of oculoplastic procedures. Six of these patients also had limb muscle biopsies. Histopathology, electron microscopy and genetic studies were performed.Results:Diagnostic histopathologic findings were present in 4/6 quadriceps biopsies, and 7/8 LP biopsies. Genetic testing on DNA extracted from LP muscle revealed abnormalities in 4 patients.Conclusion:In patients whose LP muscle demonstrate both genetic defects and histopathological abnormalities, the diagnosis of PEO can be confirmed without limb muscle biopsy. Patients having LP resection during oculoplastics procedures for treatment of ptosis may therefore be able to avoid a separate procedure for limb muscle biopsy. Further study is required to determine the specificity of these findings.
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Buttanri IB, Serin D. Levator resection in the management of myopathic ptosis. KOREAN JOURNAL OF OPHTHALMOLOGY 2014; 28:431-5. [PMID: 25435744 PMCID: PMC4239460 DOI: 10.3341/kjo.2014.28.6.431] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 03/13/2014] [Indexed: 12/01/2022] Open
Abstract
Purpose To evaluate the results of levator resection in patients with myopathic ptosis. Methods The medical records of consecutive patients who underwent levator resection surgery performed for myopathic ptosis between October 2009 and March 2013 were reviewed. Indications for surgery were ptosis obscuring the visual axis and margin-reflex distance ≤2 mm. Surgical success was defined as clear pupillary axis when the patient voluntarily opened his eye and margin-reflex distance ≥3 mm. We analyzed the effect of levator function and Bell's phenomenon on the rates of success and corneal complication. Results This series included six male and six female patients. Levator function was between 4 and 12 mm. We performed bilateral levator resection surgery in all patients. The mean follow-up time was 14.8 months (range, 6 to 36 months). No patient was overcorrected. Adequate lid elevation was achieved after the operation in 20 eyes. Ptosis recurred in three out of 20 eyes after adequate lid elevation was achieved. Our overall success rate was 70.8%. In three eyes with poor Bell's phenomenon, corneal irritation and punctate epitheliopathy that required artificial eye drops and ointments developed in the early postoperative period, although symptoms resolved completely within 2 months of the resection surgery. No patients required levator recession or any other revision surgery for lagophthalmos or corneal exposure after levator resection. Conclusions Levator resection seems to be a safe and effective procedure in myopathic patients with moderate or good Bell's phenomenon and levator function greater than 5 mm.
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Affiliation(s)
| | - Didem Serin
- Eye Clinic, Haydarpaşa Numune Education and Research Hospital, Istanbul, Turkey
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Factors affecting eyelid crease formation before and after silicone frontalis suspension for adult-onset myogenic ptosis. Ophthalmic Plast Reconstr Surg 2014; 31:227-32. [PMID: 25198392 DOI: 10.1097/iop.0000000000000272] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate factors that affect eyelid crease formation before and after frontalis suspension. DESIGN Nonrandomized, comparative, interventional case series. METHODS Sixty-three patients (125 eyes) with myogenic ptosis were included. Data collected included age, gender, previous surgeries, follow up, as well as pre- and postoperative margin reflex distance, palpebral fissure height, and levator function. Intraoperative maneuvers of incorporation of the levator aponeurosis into the skin closure, conservative fat excision, and conservative skin excision were recorded. Pre- and postoperative eyelid creases were graded by 2 masked, independent observers as "good," "fair," or "poor." RESULTS The weighted κ coefficient between the graders was 0.68 (95% CI, 0.58-0.79) preoperatively and 0.70 (95% CI, 0.61-0.79) postoperatively. Evaluating preoperative eyelid crease grades, there was no significant difference with regard to age or gender (p = 0.83 or 0.69, respectively). Eyelid crease grade correlated with margin reflex distance (p = 0.0004) and palpebral fissure height (p = 0.002). There was no significant correlation of eyelid crease with levator function (p = 0.104). After frontalis sling, intraoperative maneuvers of incorporation of the levator aponeurosis into the incision, skin preservation, and fat preservation correlated with postoperative eyelid crease (p = 0.0004, 0.059, and 0.033, respectively). CONCLUSIONS Preoperative levator function in patients with adult onset myogenic ptosis may be an inaccurate measure of true levator palpebrae strength. Reliance on levator function alone in decision making for surgical intervention in these patients may be misguided. The inclusion of the intraoperative maneuvers of incorporation of the levator aponeurosis into the skin incision and preservation of fat and skin results in a stronger eyelid crease after frontalis sling surgery.
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Abstract
Ophthalmic findings are common features of neurodegenerative disorders and, in addition to being clinically important, have emerged as potentially useful biomarkers of disease progression in several conditions. Clinically, these visual system abnormalities can be a clue to diagnosis, as well as being a prominent cause of disability in affected patients. In this Review, we describe the various afferent visual system and other ophthalmic features of inherited neurodegenerative disorders, including the muscular dystrophies, Friedreich ataxia, the spinocerebellar ataxias, hereditary spastic paraplegia, Charcot-Marie-Tooth disease, and other conditions. We focus on the expanding role of optical coherence tomography in diagnostic imaging of the retina and optic nerve head, and the possible use of ophthalmic findings as biomarkers of disease severity in hereditary neurodegenerative disorders. In addition, we discuss the ophthalmic manifestations and treatment implications of mitochondrial dysfunction, which is a feature of many inherited neurodegenerative diseases.
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Mensah A, Witting N, Duno M, Milea D, Vissing J. Delayed diagnosis of oculopharyngeal muscular dystrophy in Denmark: from initial ptosis to genetic testing. Acta Ophthalmol 2014; 92:e247-9. [PMID: 23848287 DOI: 10.1111/aos.12243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Aurore Mensah
- Department of Ophthalmology; Glostrup University Hospital; Copenhagen Denmark
| | - Nanna Witting
- Neuromuscular Research Unit; Department of Neurology, Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - Morten Duno
- Department of Clinical Genetics; University of Copenhagen; Copenhagen Denmark
| | - Dan Milea
- Department of Ophthalmology; Glostrup University Hospital; Copenhagen Denmark
- Singapore National Eye Centre; Singapore Eye Research Institute; Singapore
- Duke-NUS Neuroscience and Behavioral Disorders; Singapore
| | - John Vissing
- Neuromuscular Research Unit; Department of Neurology, Rigshospitalet; University of Copenhagen; Copenhagen Denmark
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Etezad Razavi M, Khalifeh M, Yazdani A. Comparing open and closed techniques of frontalis suspension with silicone rod for the treatment congenital blepharoptosis. Orbit 2014; 33:91-95. [PMID: 24354541 DOI: 10.3109/01676830.2013.841714] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
PURPOSE To compare open and closed methods of the frontalis suspension operation with a silicone rod in the treatment of congenital blepharoptosis. METHODS Forty-four cases with unilateral or bilateral congenital ptosis with a poor levator function of < 4 mm were divided randomly into two groups. Each group underwent an eyelid crease incision operation (open) or a supralash stab incision (closed). Ptosis was measured by the difference between the upper eyelid margin reflex distance (MRD) of the affected eyelids of the unilateral and bilateral cases. Frequent follow-up examinations were performed up to 12 months post-surgery. RESULTS Associated ophthalmologic findings showed that amblyopia, strabismus, wound discharge and knot dehiscence problems were present in 36.6%, 27.3%, 8.5% and 8.5% of the patients, respectively. There was no significant difference between the abovementioned associated ophthalmic findings of the two operative methods studied (P = 0.37). The difference in the surgical methods and MRD 3, 6 and 12 months after operation did not reach statistical significance. Similar results for good MRD (3 < MRD < 5) were found in closed (54.5%, 12/22) and open (54.5%, 12/22) methods, while 40.9% (9/22) and 45.5% (10/22) of cases were attributed to the under correction group in the closed and open methods, respectively. In bilaterally operated cases, MRD was more symmetrical than in unilaterally operated eyes. The symmetry of MRD and the eyelid crease was more prevalent in the open technique group. CONCLUSIONS The frontalis sling operation using a silicone rod exhibited better results, in terms of symmetry, in the open technique in comparison to the closed method.
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Affiliation(s)
- Mohammad Etezad Razavi
- Eye Research Center, Khatam-Al-Anbia Eye Hospital, Mashhad University of Medical Sciences , Mashhad , Iran
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Epiretinal membrane: a treatable cause of visual disability in myotonic dystrophy type 1. J Neurol 2013; 261:37-44. [DOI: 10.1007/s00415-013-7141-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 09/30/2013] [Accepted: 09/30/2013] [Indexed: 10/26/2022]
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Clinical and Demographic Characteristics of Ptosis in Children: A National Tertiary Hospital Study. Eur J Ophthalmol 2013; 23:356-60. [PMID: 23483501 DOI: 10.5301/ejo.5000239] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2012] [Indexed: 11/20/2022]
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Abstract
OBJECTIVE To retrospectively analyse surgical outcome and complications in patients with ocular myopathy undergoing ptosis correction and to introduce preoperative prophylactic lower lid elevation in this group. METHODS The medical records of all ocular myopathy patients who had undergone oculoplastic surgery between June 1995 and May 2006 were obtained. Patients' demographics, surgical details and measurements, and complications were recorded. RESULTS 29 patients were identified; 21 with chronic progressive external ophthalmoplegia (CPEO), 7 with myotonic dystrophy (MD) and 1 with oculopharyngeal muscular dystrophy (OPMD). Then, 61 procedures to adjust eyelid height were performed, comprising levator resection, brow suspension, anterior lamellar repositioning, lower lid elevation and upper lid lowering. Palpebral aperture was significantly increased in all patient groups, by procedure and diagnosis, more significantly following brow suspension compared with levator resection. The patients' feedback was very positive. Post-operative complications were few, included corneal exposure and ulceration, ptosis recurrence, arched brow, and sling infection, all of which were successfully treated. CONCLUSION Our results demonstrate subjective and objective benefit following surgery in these patients, with a low complication rate. The use of pre-operative prophylactic lower lid elevation procedures is a promising modality.
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Affiliation(s)
- Mark Doherty
- Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom.
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Nonophthalmic symptoms secondary to ocular torticollis from severe blepharoptosis: an underappreciated but treatable condition. Ophthalmic Plast Reconstr Surg 2012; 28:e36-9. [PMID: 21562438 DOI: 10.1097/iop.0b013e3182191be3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purpose of this case report is to describe reversible systemic symptoms associated with ocular torticollis due to blepharoptosis. A retrospective chart review identified patients with symptomatic ocular torticollis due to bilateral congenital or acquired blepharoptosis who underwent surgical correction (levator resection or frontalis sling). Preoperative and postoperative assessment of systemic symptoms in adults and developmental milestones are reported. The authors present 4 cases, 1 adult and 3 young children, all with severe bilateral upper eyelid ptosis. In the adult patient, it caused debilitating back pain that required orthopedic evaluation but was completely relieved with ptosis repair surgery. In the toddlers, subjective developmental motor delay was rapidly reversed following ptosis repair surgery. The authors suggest that primary care physicians, and spine and neuromuscular specialists, consider the possibility of ocular torticollis due to eyelid ptosis in the evaluation of patients with unexplained back and/or neck pain or with gross motor developmental delay. The authors propose that symptomatic ocular torticollis is an indication for ptosis repair.
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Walang B, Rath S, Sharma S. Nontuberculous mycobacterial infection after frontalis sling surgery using silicone rod. J Ophthalmic Inflamm Infect 2012; 2:219-21. [PMID: 22477624 PMCID: PMC3500978 DOI: 10.1007/s12348-012-0073-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2012] [Accepted: 03/22/2012] [Indexed: 10/28/2022] Open
Abstract
PURPOSE The purpose of this study is to report a case of nontuberculous mycobacterial infection after frontalis sling surgery. METHOD A 65-year-old man presented with bilateral painful, erythematous lesions in the brow and upper eyelids. He had a history of frontalis sling surgery for myopathic ptosis 2 years back and all lesions were found localized to the tract of the silicone rod used in the previous frontalis sling surgery. RESULT Incision and drainage of the lesions with microbiological analysis revealed significant growth of coagulase negative staphylococcus and Mycobacterium fortuitum. Sensitivity-based antibiotic treatment with intravenous amikacin was started, but poor response necessitated eventual explantation of both silicone rods for relief of symptoms. Culture of the explanted rods revealed similar results of M. fortuitum infection. Five months after the acute presentation, the patient is asymptomatic. CONCLUSION Nontuberculous mycobacterial infection may be a delayed onset complication in frontalis sling surgery using silicone rods.
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Affiliation(s)
- Batriti Walang
- Ophthalmic Plastic & Reconstructive Surgery, Orbit, and Ocular Oncology Service, L V Prasad Eye Institute, Bhubaneswar, Orissa, India, 751024
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Wang CH, Dowling JJ, North K, Schroth MK, Sejersen T, Shapiro F, Bellini J, Weiss H, Guillet M, Amburgey K, Apkon S, Bertini E, Bonnemann C, Clarke N, Connolly AM, Estournet-Mathiaud B, Fitzgerald D, Florence JM, Gee R, Gurgel-Giannetti J, Glanzman AM, Hofmeister B, Jungbluth H, Koumbourlis AC, Laing NG, Main M, Morrison LA, Munns C, Rose K, Schuler PM, Sewry C, Storhaug K, Vainzof M, Yuan N. Consensus statement on standard of care for congenital myopathies. J Child Neurol 2012; 27:363-82. [PMID: 22431881 PMCID: PMC5234865 DOI: 10.1177/0883073812436605] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Recent progress in scientific research has facilitated accurate genetic and neuropathological diagnosis of congenital myopathies. However, given their relatively low incidence, congenital myopathies remain unfamiliar to the majority of care providers, and the levels of patient care are extremely variable. This consensus statement aims to provide care guidelines for congenital myopathies. The International Standard of Care Committee for Congenital Myopathies worked through frequent e-mail correspondences, periodic conference calls, 2 rounds of online surveys, and a 3-day workshop to achieve a consensus for diagnostic and clinical care recommendations. The committee includes 59 members from 10 medical disciplines. They are organized into 5 working groups: genetics/diagnosis, neurology, pulmonology, gastroenterology/nutrition/speech/oral care, and orthopedics/rehabilitation. In each care area the authors summarize the committee's recommendations for symptom assessments and therapeutic interventions. It is the committee's goal that through these recommendations, patients with congenital myopathies will receive optimal care and improve their disease outcome.
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Affiliation(s)
- Ching H. Wang
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | | - Mary K. Schroth
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | | | | | - Hali Weiss
- Stanford University School of Medicine, Stanford, CA, USA
| | - Marc Guillet
- A Foundation Building Strength, Palo Alto, CA, USA
| | | | - Susan Apkon
- Seattle Children’s Hospital, Seattle, WA, USA
| | | | | | | | | | | | | | | | - Richard Gee
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | - Kari Storhaug
- National Resource Centre for Oral Health in Rare Medical Conditions, Oslo Norway
| | | | - Nanci Yuan
- Stanford University School of Medicine, Stanford, CA, USA
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Di Rosa L, Pirrello R, Russa G, Carita S, Morreale Bubella D, Lodato G. Deep levator palpebrae superioris detachment during aponeurosis surgery via transcutaneous approach in ptosis correction. J Fr Ophtalmol 2011; 35:166-9. [PMID: 22172368 DOI: 10.1016/j.jfo.2011.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Revised: 05/22/2011] [Accepted: 06/03/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE To evaluate the efficacy of deep levator palpebrae superioris - Müller's muscle complex detachment from conjunctiva and other connective tissues in order to improve post operative lid opening and levator function for ptosis surgery via the transcutaneous approach. METHODS In this retrospective study, 23 patients (29 eyelids) were surgically treated for ptosis repair between 2003 and 2008. All surgery was performed by the same surgeon. Patients were divided into 2 groups. The first group (12 patients) consisted of patients who underwent deep levator dissection during surgery; the second group (11 patients), used as control group, consisted of patients treated without deep levator dissection. Postoperative lid opening was compared in the two groups using the Mann-Whitney non-parametric test. RESULTS The comparison between change in lid opening changes between the two groups was statistically significant (P<0.01). CONCLUSIONS Deep levator detachment can be included among standard surgical steps during ptosis surgery via transcutaneous approach in order to improve postoperative lid opening and levator function.
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Affiliation(s)
- L Di Rosa
- University eye hospital, Via Liborio Giuffre' 13, 90127 Palermo, Italy.
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Karri B, Sebastian RT, Kyle G, Hart IK, Mountford RC. Ptosis as the Only Presenting Feature of a Mitochondrial Cytopathy. Neuroophthalmology 2011. [DOI: 10.3109/01658107.2011.615453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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[Small-incision, minimal dissection procedure (Frueh's procedure) in correction of involutional and congenital ptosis: A retrospective study of 119 cases]. J Fr Ophtalmol 2011; 34:439-47. [PMID: 21550689 DOI: 10.1016/j.jfo.2011.01.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Revised: 01/03/2011] [Accepted: 01/05/2011] [Indexed: 11/22/2022]
Abstract
PURPOSE To evaluate the efficacy and efficiency of the new small anterior incision, small-incision dissection procedure (Frueh's procedure) for the correction of involutional and congenital blepharoptosis. PATIENTS AND METHODS This was a retrospective study to compare different parameters between Frueh's procedure and the traditional aponeurotic anterior approach in a group of 98 involutional blepharoptosis patients and between Frueh's procedure and Whitnall's sling in a group of 21 congenital blepharoptosis patients. The main criterion was recurrence requiring reintervention. RESULTS In the adult's group, the rate of reoperation was not significantly different for the two surgical procedures (p=0.82). In the children's group, the rate of reoperation was not significantly different for the two surgical procedures (p=0.3). DISCUSSION In adults, compared with the traditional aponeurotic approach, Frueh's procedure for blepharoptosis correction is equally efficacious in correcting eyelid height, superior in producing desirable eyelid contour, and much quicker to perform. In children, Frueh's procedure is a good technique for mild and moderate blepharoptosis with a good levator function. However, Frueh's procedure in severe blepharoptosis with low levator function seems not to be as efficient as the traditional surgical techniques. CONCLUSION This study confirms Frueh's procedure as a reference for the treatment of adults and children with blepharoptosis.
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Takahashi Y, Leibovitch I, Kakizaki H. Frontalis suspension surgery in upper eyelid blepharoptosis. Open Ophthalmol J 2010; 4:91-7. [PMID: 21331314 PMCID: PMC3040462 DOI: 10.2174/1874364101004010091] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Revised: 06/25/2010] [Accepted: 07/19/2010] [Indexed: 11/22/2022] Open
Abstract
Frontalis suspension is a commonly used surgery that is indicated in patients with blepharoptosis and poor levator muscle function. The surgery is based on connecting the tarsal plate to the eyebrow with various sling materials. Although fascia lata is most commonly used due to its long-lasting effect and low rate of complications, it has several limitations such as difficulty of harvesting, insufficient amounts in small children, and postoperative donor-site complications. Other sling materials have overcome these limitations, but on the other hand, have been reported to be associated with other complications. In this review we focus on the different techniques and materials which are used in frontalis suspension surgeries, as well as the advantage and disadvantage of these techniques.
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Affiliation(s)
- Yasuhiro Takahashi
- Department of Ophthalmology, Aichi Medical University, Nagakute, Aichi 480-1195, Japan
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Noma K, Takahashi Y, Leibovitch I, Kakizaki H. Transcutaneous Blepharoptosis Surgery: Simultaneous Advancement of the Levator Aponeurosis and Müller's Muscle (Levator Resection). Open Ophthalmol J 2010; 4:71-5. [PMID: 21293731 PMCID: PMC3032226 DOI: 10.2174/1874364101004010071] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Revised: 06/25/2010] [Accepted: 07/19/2010] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Kazunami Noma
- Noma Eye Clinic, Kokutaiji, Naka-ku, Hiroshima 730-0042, Japan
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Pruitt JA, Ilsen PF. On the frontline: what an optometrist needs to know about myasthenia gravis. ACTA ACUST UNITED AC 2010; 81:454-60. [PMID: 20655284 DOI: 10.1016/j.optm.2009.09.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Revised: 09/11/2009] [Accepted: 09/25/2009] [Indexed: 10/19/2022]
Abstract
BACKGROUND Myasthenia gravis (MG) is an autoimmune disease that affects the voluntary skeletal muscles. It is characterized by transient weakness of the muscles that improves with rest. Muscle weakness involving the eyes can produce signs or symptoms of diplopia, blurred vision, ptosis, and ophthalmoplegia. Ptosis is defined as an abnormal eyelid "drooping" beyond the normal 1 to 2 mm of the upper limbus of the cornea. Hence, most patients with MG have ophthalmic manifestations. Among all patients with MG, up to half will have exclusively ocular symptoms. In these cases, the condition is referred to as ocular myasthenia. CASE REPORT A 60-year-old man was referred from a neurology clinic for management of intermittent diplopia for greater than 1 year and intermittent bilateral ptosis for the prior year. He reported that he first noticed symptoms of MG at the age of 42, but did not receive the diagnosis until 1 year before his aforementioned neurology examination. He was prescribed spectacles with bilateral ptosis crutches. A diagnosis of severe seronegative MG was subsequently confirmed with neurologic examination and antibody testing. CONCLUSIONS Because patients with undiagnosed myasthenia gravis may present initially with ocular signs or symptoms, it is important for the optometrist to be familiar with the condition and the simple "in-office" tests that can be performed to establish a tentative diagnosis and management plan. The optometrist can also participate in the management of ocular manifestations of myasthenia and should be familiar with the use of a ptosis crutch (in addition to prism spectacles or occlusion therapies if indicated) as a nonsurgical intervention for ptosis.
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Affiliation(s)
- Joseph A Pruitt
- Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota 55417, USA.
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