Eyelid malposition after cataract and refractive surgery

Oculoplastic Surgeries in Patients Older than 90 Years of Age

PURPOSE

To report the epidemiology, indications and surgical outcomes of oculoplastic surgeries in older adults (≥ 90 years old).

METHODS

A retrospective study was conducted reviewing the medical charts of 114 patients aged 90 years old and older who underwent oculoplastic procedures from 2010 to 2020. Data retrieved from the medical records included: past medical and ocular history, indication for surgery, type of surgery, intra and post-operative complications, pathological analysis for removed tissues, and surgical outcome in the last follow-up.

RESULTS

One hundred and twenty eight surgeries were performed on 114 patients (male: female = 1:1). The mean age was 92.95 years old (± 3.12 SD). Six patients (5.2%) were older than 100 years old. The most common indication for surgery was lower lid malpositioning (32%). Mass/lesion excision was performed in 34 procedures (25%). Forty-three biopsies were analyzed and basal cell carcinoma was found to be the most common pathological diagnosis (32%). Hypertension was the most common associated systemic comorbidity (79 patients, 69%). 80% of the surgeries were performed under local anesthesia. Surgical revision was required in seven patients (5.2%). One patient had suffered from a minor stroke one day after the surgical pocedure. The same patient had orbital-skin fistulas after orbital exenteration.

CONCLUSION

In our experience, oculoplastic surgeries among the elderly population are safe without significant complications and can usually be performed under local anesthesia. Advanced age should not prevent surgery, especially if the procedure may improve vision and quality of life.

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

OBJECTIVE

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

DESIGN

Retrospective case series.

PARTICIPANTS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Postoperative Blepharoptosis After Pars Plana Vitrectomy Procedure

PURPOSE

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

METHODS

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

RESULT

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

CONCLUSION

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

Postoperative Blepharoptosis After Modern Phacoemulsification Procedure

PURPOSE

To investigate the frequency of transient (1 month) and persistent (at least 6 months) postoperative ptosis following clear corneal sutureless phacoemulsification and to analyze the factors affecting them.

DESIGN

Cohort study.

METHODS

Patients who underwent phacoemulsification cataract surgery from October 2016 to June 2018 in a tertiary center were enrolled. Margin reflex distance 1 (MRD1), MRD2, and levator function were measured and facial photography was taken before, 1 month, and at least 6 months after the surgery. Clinical ptosis was defined as any postoperative drop of MRD1 and clinically significant ptosis as MRD1 drop of ≥2 mm. Photo-based ptosis was assessed by a masked oculofacial plastic surgeon at the end of the study.

RESULTS

A total of 234 patients (313 eyelids) were included. The majority of surgeries were performed by senior residents (65.5%, 205/313) and under topical anesthesia (78.0%, 244/313). Persistent clinical, clinically significant, and photo-based ptosis were 25.4% (71/279), 3.2% (9/279), and 3.3% (9/276). Eyelids with persistent postoperative ptosis showed a significantly (P = .03) lower preoperative levator function (13.9 vs 15.8 mm). No other factor was significantly different between the eyelids with and without postoperative ptosis.

CONCLUSION

Persistent clinically significant ptosis was observed in more than 3% of patients undergoing clear corneal sutureless phacoemulsification cataract surgery. It should be counseled preoperatively. Lower preoperative levator function was significantly associated with a higher frequency of postoperative ptosis. Duration of surgery, level of surgeons, and other variables did not have any significant effect on the frequency of postoperative ptosis.

An Objective Evaluation of the Upper Eyelid Position after Phacoemulsification Cataract Surgery

Purpose: To objectively measure the upper eyelid position following phacoemulsification cataract surgery and to identify the determinants of postoperative transient ptosis. Methods: This is a single arm prospective study of patients who underwent cataract surgery from January to May 2017 at a tertiary Eye Hospital in Spain. Data comprised of: the type of anesthesia, the duration that the speculum remained in place and the total surgical time (duration of the procedure). The total surgical time was defined as, the time from the beginning of the paracentesis to the closure of the wounds (incision time). Digital photographs were obtained of: the face with the eye in primary gaze, looking inferiorly and superiorly, preoperatively, and 1, 30, 90 and 180 days postoperatively. Measurements for eyelid crease, levator function, and marginal reflex distance 1 (MRD1) were performed using ImageJ. Statistical analysis was performed of the difference between the preoperative and postoperative measurements. Results: The study consisted of 112 patients. The median lid crease was 9.0 mm [IQR (interquartile range) 7.5; 10.0] both preoperatively and at 180 days postoperatively (IQR 8.0; 10.8). No statistical difference was determined in the lid crease measurements between these two times (P = .17). The median levator function differed significantly preoperatively, at day 1 and 30, 60 and 180 days postoperatively (P < .01). MRD1 decreased significantly from a median of 3.01 mm preoperatively to 2.7 mm at 30 days postoperatively (P = .05) but was similar at preoperative and after 180 days (P = .7). The correlation of MRD1 to the duration of the speculum in place (P = .2) and the incision time (P = .57) was not significant. Conclusions: Ptosis, following phacoemulsification cataract surgery, is mild and transient, occurring only in the early postoperative period.

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

OBJECTIVE

We conducted a systematic review and meta-analysis to evaluate the incidence and risk factors of ptosis following ocular surgery.

METHODS

PubMed, Embase, and Cochrane Library were searched for articles that assessed the incidence or risk factors of ptosis following ocular surgery up to October 2017. We used a fixed effects model to calculate a pooled estimate of incidence, with subgroup analyses to evaluate the effect of different variables. The relative risks (RRs) or odds ratios (ORs) and 95% confidence intervals (CIs) for all available factors were calculated using the fixed effects models.

RESULTS

A total of 16 studies on 2856 eyes were analyzed, including 3 randomized controlled trials (RCTs) and 13 cohort studies. The overall incidence of ptosis following ocular surgery was 11.4% (95% CI 10.1-12.8%). Subgroup analyses showed that the region and the surgery type were significantly associated with the incidence of postoperative ptosis. Men were less likely to get postoperative ptosis than women (OR 0.62; 95% CI 0.43-0.89). However, age (OR 0.77; 95% CI 0.48-1.23), side (OR 1.37; 95% CI 0.84-2.25), type of anesthesia (OR 0.57; 95% CI 0.16-2.05), prior surgery (OR 1.09; 95% CI 0.64-1.83), bridle suture (OR 2.04; 95% CI 0.94-4.42), or combined surgery (OR 0.95; 95% CI 0.58-1.57) did not significantly change the risk of ptosis following ocular surgery.

CONCLUSION

More than one in ten patients who undergo ocular surgery will develop ptosis. Different regions and surgery types may influence the occurrence of this abnormality. Female gender is a risk factor for development of postoperative ptosis.

Response to phenylephrine testing in upper eyelids with ptosis

OBJECTIVE

To evaluate the response of ptotic upper eyelids to topical phenylephrine 10%.

METHODS

The medical records of patients referred for ptosis evaluation over an 18-month period were retrospectively reviewed. Seventy-seven ptotic upper eyelids with aponeurotic dehiscence in 47 patients were given 1 drop of 10% phenylephrine. Margin-to-reflex distance 1 (MRD1) and levator excursion were recorded and photography of lid height was performed both pre- and 5 minutes post-phenylephrine testing.

RESULTS

A total of 77 ptotic upper eyelids of 47 patients were included. In 22% of lids, phenylephrine testing produced no response; in 18%, lid elevation of 0.5-1 mm; in 35%, elevation of 1.5-2 mm; and in 25%, elevation of > 2 mm. Subgroup analyses revealed a higher proportion of response in cases of mild to moderate ptosis compared with cases of severe ptosis. The amount of levator function in these cases of aponeurotic dehiscence did not correlate with the amount of response to phenylephrine.

CONCLUSIONS

A majority of ptotic eyelids, regardless of levator function, responded to topical phenylephrine, which has been demonstrated to be necessary for successful Müller's muscle resection ptosis repair. While the severity of ptosis was linked to eyelid response to phenylephrine, the degree of levator function did not appear to affect an eyelid's response to phenylephrine. In this study cohort, phenylephrine was shown to stimulate Müller's muscle contraction independently of levator function.

Blepharoptosis following anterior segment surgery: a new theory for an old problem

Blepharoptosis is a well-known complication following anterior segment surgery. However, its precise aetiology remains elusive. There are currently two widely held views on the pathogenesis of persistent postoperative ptosis, namely the speculum and bridle suture theories. However, both suggested explanations fail to address important anatomical and epidemiological features of this condition. Until now, the majority of published literature describing persistent postoperative ptosis following anterior segment surgery has largely concentrated on dehiscence of the levator aponeurosis as the common mechanism underlying this postoperative complication. However, numerous studies have failed to show any correlation between pre or postoperative skin crease positions in such patients. This review article discusses previously proposed mechanisms responsible for both transient and persistent ptosis. Furthermore, we propose an alternative mechanism for the development of ptosis following anterior segment surgery, namely horizontal stretch of the upper eyelid induced by the use of the speculum. This mechanism also provides a plausible explanation for less commonly described oculoplastic complications, such as lower lid malpositions, following anterior segment surgery. Postoperative ptosis may also act as a paradigm for the development of involutional ptosis in general. In view of the frequency with which ophthalmologists perform anterior segment procedures such as cataract surgery, postoperative ptosis represents a significant concern for all ocular surgeons. Identifying the underlying mechanism is imperative, not only to identify those patients at greatest risk, but also to perhaps provide novel surgical approaches to the management of this complication.