Transblepharoplasty Ptosis Repair: Three-Step Technique

Congenital ptosis with aponeurotic maldevelopment: clinical and surgical perspectives : Aponeurotic maldevelopment in congenital ptosis

PURPOSE

Levator muscle dystrophy has been commonly accused being the main pathology of congenital ptosis, nevertheless, few reports drew attention to the existence of congenital aponeurotic defects. This study aims at highlighting the detailed clinical and surgical features of aponeurotic maldevelopment together with the efficacy of simple aponeurosis repair.

METHODS

This is a retrospective nonrandomised study including patients with congenital ptosis who underwent levator muscle surgery throughout 4 years. Patients' records were reviewed for the preoperative clinical assessment and photographs, intraoperative recorded data, and videos as well as postoperative data and photographs.

RESULTS

Twenty-seven eyes of 22 patients (9.4%) out of 287 eyes were recorded to have absent levator muscle at its typical anatomical insertion site intraoperatively. The mean preoperative MRD1 was (0.44 ± 1.17 mm). The mean levator function was 8.56 ± 3.89 mm, with higher-than-normal crease position (mean value 10.07 ± 1.62 mm). 25 eyes of included cases (92.6%) showed total absence of the levator aponeurosis edge which only was revealed after cutting through the orbital septal covering of the preaponeurotic fat.

CONCLUSION

Congenital aponeurotic defect is an established yet under reported entity of congenital ptosis with reproducible characteristic intraoperative findings. Simple aponeurosis repair could achieve ptosis correction in such cases.

Conjoint Fascial Sheath Suspension for Correction of Severe Involutional Blepharoptosis

Involutional ptosis is considered to be the result of the disinsertion of the levator aponeurosis from the tarsal plate. However, present histopathological studies indicate that the pathogenesis of involutional ptosis is multifactorial and complex. To create a more physiologic eyelid opening in patients with severe involutional blepharoptosis, the authors used conjoint fascial sheath (CFS) as suspension location. Sixty-seven involutional blepharoptosis patients (123 eyelids) with a degree of severe ptosis (marginal reflex distance 1, MRD-1 <1.0 mm) underwent the CFS suspension. The primary outcome was MRD-1 at 12 months after surgery. Secondary outcomes were cosmetic outcomes and postoperative complications. All the eyelids had fair MRD-1 (MRD-1≥2.0 mm) at 12 months. Complete correction of ptosis (MRD-1≥2.5 mm) at 12 months was obtained in 80 eyelids (65%). There were no overcorrections. The mean cosmetic outcome by patients was 3.56 ± 0.61 at 12 months. The most common complication was reoperation, which was done in 9 eyelids (7%) because of incomplete correction. CFS suspension was effective in the treatment of severe involutional blepharoptosis. The technique produced an elevating motion of the physiologic eyelid in a superior-posterior direction.

A Comprehensive Approach to Asian Upper Eyelid Ptosis Correction: The Levator Musculo-Aponeurotic Junction Formula

BACKGROUND

The unique anatomy of the Asian upper eyelid requires specific adaptation to the levator advancement technique for ptosis correction to achieve predictable and reproducible outcomes.

OBJECTIVES

The levator musculo-aponeurotic junction was employed as they key landmark. With a formula developed by the authors, the location of fixation relative to this landmark can be predicted preoperatively. The authors' clinical experience and outcomes with this technique are presented.

METHODS

Inclusion criteria were Asian patients with mild to severe ptosis with at least fair levator function. Patients with acquired or congenital ptosis and primary and revisional cases were all included. The location for placement of the advancement sutures was measured from the musculo-aponeurotic junction of the upper eyelid levator. This distance was determined by a formula that considers (1) the amount of elevation of the upper eyelid margin needed, (2) the degree of compensatory brow elevation present, and (3) eye dominance.

RESULTS

A total 156 Asian patients were included in this prospective study. Of these, 148 were bilateral and 8 were unilateral corrections. The technique was predictable with resolution of symptoms of eyelid ptosis post-surgery and good long-term symmetry of the palpebral aperture and crisp upper eyelid creases. The formula for estimating the fixation point on the levator was accurate to within ±1 mm in the majority of patients. The aperture revision rate was 2%.

CONCLUSIONS

This novel technique provides a predictable and reliable approach for upper eyelid ptosis correction in Asian patients.

LEVEL OF EVIDENCE: 4

Factors that influence the postoperative upper eyelid position following surgery for involutional blepharoptosis

External levator advancement is commonly performed for involutional blepharoptosis repair; however, it is difficult to predict the postoperative upper eyelid position (UEP) accurately in blepharoptosis surgery. The purpose of this study was to determine the factors that influence postoperative UEP following surgery for involutional blepharoptosis. We retrospectively studied 40 Japanese women (80 eyelids) who underwent bilateral external levator advancement surgery. We used digital analysis software to measure the UEP and the eyebrow position from straight-gaze view photographs. Statistical analysis was performed to determine the correlation between postoperative UEP and related factors, including age, levator function, amount of levator advancement, anatomical fixed position, and preoperative and intraoperative UEP. We also compared UEP changes in mild, moderate, and severe ptosis groups. Levator function affected both preoperative and postoperative UEP. The amount of levator advancement and the anatomical fixation position on the aponeurosis did not affect the postoperative UEP. However, both preoperative (r = 0.49) and intraoperative (r = 0.55) UEPs affected the postoperative UEP. In cases of severe ptosis, there was significant re-drooping after surgery, while in cases with mild ptosis, the intraoperative eyelid position was maintained or slightly elevated. In involutional blepharoptosis, the degree of preoperative and intraoperative UEP contributed to the postoperative eyelid position. These data suggested that the levator muscle function is a major contributing factor in the pathogenesis of involutional blepharoptosis.

Influence of fatty deposits in the levator aponeurosis/levator palpebrae superioris muscle on outcomes of aponeurotic repair in a Japanese population

PURPOSE

To examine a part of the levator aponeurosis/levator palpebrae superioris (LPS) muscle that did not have fatty deposits in patients with aponeurotic blepharoptosis. We also analysed the relation between this length and surgical outcome after transcutaneous aponeurotic repair.

METHODS

We measured the vertical length from the distal end of the anterior layer of the levator aponeurosis to the most distal point of fatty deposits in the levator aponeurosis/LPS muscle (non-fatty-deposit length) in 94 eyelids. Surgical success was defined as a postoperative margin reflex distance-1 (MRD-1) of 2.0-5.0 mm at 3 months postoperatively. The eyelids were classified into two groups: a surgical success group (group A, 76 eyelids) and an undercorrected group (group B, 18 eyelids). Group A was subdivided according to the evidence of a fatty deposit (group A1, fat present, 70 eyelids; group A2, fat absent, 6 eyelids).

RESULTS

The non-fatty-deposit measurement was significantly longer in group A1 than in group B (p = 0.035). The levator aponeurosis was less advanced in groups A1 and A2 than in group B (both, p < 0.001), and the eyelids in groups A1 and A2 obtained a higher MRD-1 than those in group B (both, p < 0.001).

CONCLUSIONS

Eyelids with less fat deposit required less advancement of the levator aponeurosis and obtained more favourable surgical results. Intraoperative findings of eyelids with and without fatty deposits and measuring the non-fatty-deposit length may be useful predictive parameters for outcomes of transcutaneous aponeurotic repair.

Comparison of Revision Rates of Anterior- and Posterior-Approach Ptosis Surgery: A Retrospective Review of 1519 Cases

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.

Determination of the Amount of Ptosis Correction in Levator Resection Surgery for Pediatric Congenital Ptosis

BACKGROUND

It is difficult to determine the amount of eyelid lift in levator resection surgery for congenital ptosis, especially when the surgery is performed under general anesthesia. We aim to introduce an objective and steady method with which to adjust eyelid height, and to identify other factors to be considered during surgery.

METHODS

This is a retrospective, observational study of 110 eyes from 78 patients who underwent levator resection surgery for congenital ptosis. Postoperative eyelid height was observed chronologically. The amount of eyelid lift during surgery was compared with the real postoperative change of palpebral fissure width (PF). The factors influencing the postoperative changes in eyelid height were investigated to predict outcome.

RESULTS

Postoperative eyelid height stabilized 1 month after surgery. The real postoperative change in PF was slightly larger than the amount of intraoperative eyelid lift in cases with levator muscle function (LF) ≥ 7 mm, whereas it tended to be smaller in cases with LF < 5 mm. Statistically significant factors influencing the difference between the amount of intraoperative eyelid lift and the real postoperative change of eyelid height included preoperative PF, preoperative LF, and anesthesia-induced lagophthalmos.

CONCLUSION

The preoperative PF, preoperative LF, and anesthesia-induced lagophthalmos should be considered when determining the amount of ptosis correction to perform in levator resection surgery.

LEVEL OF EVIDENCE IV

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Outcomes of adult aponeurotic ptosis repair under general anaesthesia by a posterior approach white-line levator advancement

Aponeurotic ptosis surgery is conventionally performed under local anaesthetic to allow adjustment of eyelid height and contour. This may not be possible where general anaesthesia (GA) is required.

PURPOSE

We describe our experience using a tranconjunctival posterior approach "white-line" levator advancement (WLA) in patients undergoing aponeurotic ptosis correction under a GA.

MATERIALS AND METHODS

Retrospective review of a consecutive series of 20 patients with primary aponeurotic ptosis undergoing posterior approach WLA ptosis repair under GA. The procedure involves exposing the posterior surface of the levator aponeurosis and advancement through tarsus onto its anterior surface if exposed already, or to skin. All patients underwent pre- and postoperative photographs and final outcomes were assessed at minimum 3 months. Outcome measures included pre- and post-marginal reflex distance (MRD), symmetry of height, contour, fold and complications including dry eye.

RESULTS

Twenty patients undergoing 40 procedures were included. Mean age was 58 (22-87) years. Mean preoperative MRD was 1.3. Preoperative phenylephrine test was positive all patients. The mean postoperative MRD was 3.5 mm. Although all 20 patients achieved their desired lid height and contour, one patient had a 2 mm asymmetry, with a final success rate of 95% (19/20 patients).

CONCLUSION

We suggest that a posterior approach white-line advancement is an ideal technique to correct even severe aponeurotic ptosis in patients requiring surgery under GA. Preoperative positive phenylephrine test is a good predictor of postoperative height and contour without the need for per-operative adjustment. Précis: Aponeurotic ptosis surgery for patients under general anaesthesia using a simple posterior approach white-line advancement achieves predictability of lid height, symmetry and contour and is an ideal option for phenylephrine-positive ptosis.

On the frontline: what an optometrist needs to know about myasthenia gravis

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.

Evaluation and management of unilateral ptosis and avoiding contralateral ptosis

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