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Pornpanich K, Shanokprasith S, Jaru-Ampornpan P, Eiamsamarng A. Comparison of clinical outcomes of conjunctivo-mullerectomy for varying degrees of ptosis. Sci Rep 2023; 13:19131. [PMID: 37926725 PMCID: PMC10625983 DOI: 10.1038/s41598-023-46419-y] [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: 07/22/2023] [Accepted: 10/31/2023] [Indexed: 11/07/2023] Open
Abstract
To compare the success of conjunctivo-mullerectomy in patients with varying degrees of ptosis and identify factors affecting outcomes and complications. The prospective cohort was studied in patients with ptosis undergoing conjunctivo-mullerectomy with or without tarsectomy were enrolled. Ptosis was classified as mild, moderate, and severe per margin-to-reflex distance 1 (MRD1). Postoperative MRD1, complications, and 3-month success rates were evaluated. The study enrolled 258 ptotic eyes of 159 patients. Most eyes (233; 90.3%) achieved surgical success, 14 (5.4%) were overcorrected, and 11 (4.3%) were undercorrected. The success rates for mild, moderate, and severe ptosis were 96.6%, 91.7%, and 83.5%, respectively. The mild and moderate ptosis groups had a nonsignificant difference in success (- 4.9%; 95% CI - 12.0% to 4.5%; P = 0.36). However, the mild and severe ptosis groups' rates significantly differed (- 13.1%; 95% CI - 23.6% to - 1.9%; P = 0.03). For all 3 ptosis groups, the success rates of individuals undergoing surgery without tarsectomy did not significantly differ. Patients undergoing conjunctivo-mullerectomy with tarsectomy had an increased risk of unsuccessful surgery (OR 3.103; 95% CI 1.205-7.986; P = 0.019). In conclusions, Conjunctivo-mullerectomy is safe and effective for all ptosis severities. The success rate was significantly lower for severe ptosis than mild or moderate ptosis. Levator muscle function was not associated with unsuccessful outcomes, but tarsectomy was.
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Affiliation(s)
- Kanograt Pornpanich
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Siriraj, Bangkok Noi, Bangkok, 10700, Thailand
| | - Sunsri Shanokprasith
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Siriraj, Bangkok Noi, Bangkok, 10700, Thailand
| | - Pimkwan Jaru-Ampornpan
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Siriraj, Bangkok Noi, Bangkok, 10700, Thailand
| | - Akarawit Eiamsamarng
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Siriraj, Bangkok Noi, Bangkok, 10700, Thailand.
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Mangan MS, Tekcan H, Yurttaser Ocak S, Ozcelik Kose A, Balci S, Ercalik NY, Imamoglu S. Müller Muscle-Conjunctival Resection for Treatment of Contralateral Ptosis following Unilateral External Levator Advancement. Plast Reconstr Surg 2023; 152:533-539. [PMID: 36827478 DOI: 10.1097/prs.0000000000010309] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND One of the main causes of unsatisfactory outcomes after unilateral blepharoptosis surgery is asymmetry of the upper eyelid height, which occurs as a result of a contralateral eyelid droop. Therefore, the authors evaluated the efficacy of Müller muscle-conjunctival resection (MMCR) for the treatment of contralateral ptosis following unilateral external levator advancement (ELA). METHODS This study analyzed 26 eyelids of 26 patients with upper eyelid height asymmetry following unilateral ELA who underwent contralateral MMCR retrospectively. The phenylephrine test was performed before ELA and before MMCR. The main outcome measures were symmetry outcomes and clinical outcomes. RESULTS The mean patient age was 55.81 ± 7.98 years (range, 44 to 70 years); 15 were female (57.7%). The Hering dependency was observed in 13 of the patients (50%) before ELA. An adequate response to phenylephrine was observed before MMCR but not before ELA. Symmetry outcomes after MMCR were perfect (<0.5 mm), good (≥0.5 mm and <1 mm), and fair (≥1 mm) in seven, 17, and two patients, respectively. An optimal upper eyelid height was noted in 47 of the 52 eyelids after the MMCR, whereas three of the 52 eyelids had minimal overcorrection, and two eyelids had undercorrection. The mean change in marginal reflex distance 1 of the contralateral eyelid droop was greater for patients with than without the Hering dependency ( P < 0.0001) after ELA but not after MMCR. Two patients (7.6%) underwent revision ELA surgery. CONCLUSION MMCR and use of the phenylephrine test to predict the eyelid position may represent an alternative approach in patients who require management of contralateral ptosis following unilateral ELA. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Mehmet Serhat Mangan
- From the Division of Oculoplastic and Reconstructive Surgery, University of Health Sciences, Haydarpasa Numune Education and Research Hospital, Sadik Eratik Eye Clinic
| | - Hatice Tekcan
- From the Division of Oculoplastic and Reconstructive Surgery, University of Health Sciences, Haydarpasa Numune Education and Research Hospital, Sadik Eratik Eye Clinic
| | - Serap Yurttaser Ocak
- Department of Ophthalmology, University of Health Sciences, Okmeydani Education and Research Hospital
| | - Alev Ozcelik Kose
- From the Division of Oculoplastic and Reconstructive Surgery, University of Health Sciences, Haydarpasa Numune Education and Research Hospital, Sadik Eratik Eye Clinic
| | - Sevcan Balci
- From the Division of Oculoplastic and Reconstructive Surgery, University of Health Sciences, Haydarpasa Numune Education and Research Hospital, Sadik Eratik Eye Clinic
| | - Nimet Yesim Ercalik
- From the Division of Oculoplastic and Reconstructive Surgery, University of Health Sciences, Haydarpasa Numune Education and Research Hospital, Sadik Eratik Eye Clinic
| | - Serhat Imamoglu
- From the Division of Oculoplastic and Reconstructive Surgery, University of Health Sciences, Haydarpasa Numune Education and Research Hospital, Sadik Eratik Eye Clinic
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van Philips IOR, van Minderhout HM, Stefanovic M, van Philips LAM. Efficacy of Müller's Muscle-conjunctival Resection With or Without Suturing for the Correction of Ptosis. Ophthalmic Plast Reconstr Surg 2023; 39:254-259. [PMID: 36305788 DOI: 10.1097/iop.0000000000002302] [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: 05/12/2023]
Abstract
PURPOSE The purpose of this study was to compare the efficacy of Müller muscle-conjunctival resection (MMCR) with or without suturing for the correction of ptosis. METHODS A retrospective chart review was performed of 30 patients (56 eyelids) undergoing sutureless (sMMCR) (34 eyelids) or conventional MMCR (cMMCR) (22 eyelids). Primary outcome measures were the change in MRD1 and vertical eyelid height (VLH). Secondary outcome measures were the amount of resection of MMCR (rMMCR) and postoperative symmetry of 1 mm or less. RESULTS In total, 49 eyelids (87.5%) had involutional ptosis and 7 (12.5%) had contactlens induced ptosis. The age and follow up between the sMMCR and cMMCR groups was, respectively, 65.1 ± 11.0 versus 65.5 ± 11.0 years and 4.0 ± 2.5 versus 6.5 ± 2.1 months. Preoperatively there were no significant differences noted between the sMMCR and cMMCR groups. Postoperatively there was a statistically significant difference in change of MRD1 between the sMMCR and cMMCR groups, 2.74 ± 0.20 mm and 2.02 ± 0.25 mm ( p = 0.026). The difference in change of VLH and rMMCR was not significant between the sMMCR and cMMCR groups, 2.28 ± 0.13 mm and 2.14 ± 0.15 mm ( p = 0.49) and 9.29 ± 2.14 versus 9.46 ± 1.97 mm ( p = 0.83). There were no significant differences in postoperative symmetry. CONCLUSION The sMMCR and cMMCR techniques demonstrated equal effectiveness for the correction of ptosis. The rapid sMMCR could become the procedure of choice for the correction of involutional and contact lens induced ptosis.
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Affiliation(s)
| | - Helena M van Minderhout
- Division of Ophthalmic Plastic and Reconstructive Surgery, Department of Ophthalmology, Haaglanden Medisch Centrum, The Hague, The Netherlands
| | - Maja Stefanovic
- Division of Ophthalmic Plastic and Reconstructive Surgery, Department of Ophthalmology, Haaglanden Medisch Centrum, The Hague, The Netherlands
| | - Lucien A M van Philips
- Division of Ophthalmic Plastic and Reconstructive Surgery, Department of Ophthalmology, Haaglanden Medisch Centrum, The Hague, The Netherlands
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Muller's muscle conjunctival resection versus external levator advancement for ptosis repair: systematic review and meta-analysis. Int Ophthalmol 2023:10.1007/s10792-023-02633-1. [PMID: 36692699 DOI: 10.1007/s10792-023-02633-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 01/10/2023] [Indexed: 01/25/2023]
Abstract
PURPOSE To compare the outcome of Muller's muscle conjunctival resection (MMCR) versus external levator advancement (ELA) in patients undergoing ptosis surgery. METHODS A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, and a search of electronic information was conducted to identify all comparative studies of MMCR versus ELA in ptosis repair. The primary outcome measures were the post-operative marginal reflex distance (MRD1), ptosis under-correction, over-correction, and re-operation rate. Secondary outcome measures included cosmetic appearance, complications, operative time, and learning curve. Fixed-effect modelling was used for the analysis. RESULTS Seven studies that enrolled 1038 eyelids were identified in the literature. There was no statistically significant difference between the MMCR and ELA groups in post-operative MRD1 (Mean Difference [MD] = 0.13, P = 0.28) and the rate of under-correction odds ratio [OR] = 0.49, P = 0.14). However, ELA had a significantly higher rate of over-correction (OR = 0.17, P = 0.04) and re-operations (OR = 0.26, P = 0.0001) compared to MMCR. For secondary outcomes, MMCR had an improved cosmetic appearance, lower total number of complications and shorter operation time (MD = - 10.96, P < 0.00001). Finally, the two techniques had no significant difference in the learning curves. CONCLUSION Both MMCR and ELA are effective techniques for the surgical correction of ptosis; however, MMCR surgery is a more predictable and robust technique compared to, ELA with lower rates of over-correction and re-operation.
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Serefoglu Cabuk K, Asik Nacaroglu S, Ozturk Karabulut G, Fazil K, Arslan MS, Guler MG, Taskapili M. Muller muscle conjunctival resection or external levator advancement; a quantitative comparison of symmetry in unilateral ptosis. Eur J Ophthalmol 2021; 32:2125-2132. [PMID: 34704509 DOI: 10.1177/11206721211049057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To compare muller muscle conjunctival resection (MMCR) and external levator advancement (ELA) in terms of objective and subjective symmetry in unilateral ptosis. METHODS The patients who underwent unilateral MMCR (group1, n = 25) and ELA (group2, n = 25) were reviewed retrospectively. With the written algorithm, margin reflex distance-1 (MRD1), localization of the contour peak, and the percentage of overlapping curvatures (POC) of both upper eyelid curves were calculated. Semi-automated measurements were compared with the manual measurements. The correlation between objective and subjective symmetry was evaluated. RESULTS Preoperative levator functions were similar in both groups (13.93 ± 3.25 mm and 13.3 ± 2.86 mm, respectively). We found strong correlations between manual and semi-automated measurements (ICC: 0.942, 95% CI = 0.924-0.956, p < 0.001). Preoperative MRD1 (2.15 ± 0.90 vs 1.51 ± 1.01, p = 0.022) and POC was lower in group 2 (66% vs 47.2%, p = 0.01). In the postoperative period, the increase in MRD1 and POC were similar in both groups (p = 0.2 and p = 0.7 respectively), and the contour peak displaced temporally (p < 0.01) providing a symmetric peak in both groups. Subjective symmetry increased as the difference in MRD1 between two eyes decreased (r = -0.456, p = 0.001), and POC increased (r = 0.396, p = 0.004). CONCLUSIONS Besides subjective symmetry, MMCR and ELA are equally effective in ensuring symmetry objectively, as measured with MRD1 and contour peak symmetry and POC in unilateral ptosis. POC may be used as a criterion of symmetry in the evaluation of ptosis.
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Affiliation(s)
- Kubra Serefoglu Cabuk
- 147017University of Health Sciences Beyoglu Eye Training and Research Hospital, Ophthalmic Plastic and Reconstructive Surgery, Istanbul, Turkey
| | - Senay Asik Nacaroglu
- 147017University of Health Sciences Beyoglu Eye Training and Research Hospital, Ophthalmic Plastic and Reconstructive Surgery, Istanbul, Turkey
| | - Gamze Ozturk Karabulut
- 147017University of Health Sciences Beyoglu Eye Training and Research Hospital, Ophthalmic Plastic and Reconstructive Surgery, Istanbul, Turkey
| | - Korhan Fazil
- 147017University of Health Sciences Beyoglu Eye Training and Research Hospital, Ophthalmic Plastic and Reconstructive Surgery, Istanbul, Turkey
| | - Mehmet Selcuk Arslan
- 52999Yildiz Technical University, Department of Mechatronics Engineering, Istanbul, Turkey
| | - Mehmet Guray Guler
- 52999Yildiz Technical University, Department of Industrial Engineering, Istanbul, Turkey
| | - Muhittin Taskapili
- 147017University of Health Sciences Beyoglu Eye Training and Research Hospital, Ophthalmic Plastic and Reconstructive Surgery, Istanbul, Turkey
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Mangan MS, Cakir A, Imamoglu S. Cumulative sum analysis of the learning curve of ptosis surgery: External levator advancement versus Müller's muscle-conjunctival resection. ACTA ACUST UNITED AC 2021; 35:383-390. [PMID: 34344132 PMCID: PMC8521322 DOI: 10.3341/kjo.2021.0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/15/2021] [Indexed: 12/03/2022]
Abstract
Purpose Even though it is stated that external levator advancement (ELA) has a much longer learning curve than Müller muscle-conjunctival resection (MMCR) in the treatment of aponeurotic ptosis, there is no study in the literature regarding the learning curves of these two surgical techniques. We aimed to objectively determine the length of the learning curves of ELA and MMCR using cumulative sum (CUSUM) analysis. Methods The first 30 unilateral ELA and the first 30 unilateral MMCR consecutively performed by a single surgeon were retrospectively reviewed. The CUSUM method was used to analyze the learning curves of ELA and MMCR based on operation times of consecutive surgeries and the clinical outcomes were compared. Results CUSUM analyses revealed that the operation time stabilized after around 11 ELA surgeries and 12 MMCR surgeries and R2 value for ELA and MMCR were 0.93 and 0.91, respectively. There was no significant difference in these stratified analyses. Mean operation time was 45.7 minutes in the ELA group and 34.1 minutes in the MMCR group (p = 0.002). Total number of intraoperative complications was 37 in the ELA group and 16 in the MMCR group (p = 0.015). Symmetry success rate was significantly higher (p < 0.0001) and reoperation rate was significantly lower in the MMCR group (p = 0.045). Conclusions Even though ELA is more challenging than MMCR, comparable learning curves indicate that surgeons in training need to be encouraged to perform both techniques. The challenges and obstacles that the surgeons in training face in these two techniques need to be analyzed in detail.
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Affiliation(s)
- Mehmet Serhat Mangan
- University of Health Sciences, Haydarpasa Numune Education and Research Hospital, Sadik Eratik Eye Institute, Division of Oculoplastic and Reconstructive Surgery, Istanbul, Turkey
| | - Akin Cakir
- University of Health Sciences, Okmeydani Education and Research Hospital, Department of Ophthalmology, Istanbul, Turkey
| | - Serhat Imamoglu
- University of Health Sciences, Haydarpasa Numune Education and Research Hospital, Sadik Eratik Eye Institute, Division of Oculoplastic and Reconstructive Surgery, Istanbul, Turkey
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7
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Combined Botox and Muller's Muscle-Conjunctival Resection in the Treatment of Patients With Blepharospasm and Blepharoptosis. Ophthalmic Plast Reconstr Surg 2021; 37:S112. [PMID: 34011901 DOI: 10.1097/iop.0000000000001726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Adjustable Ptosis Correction via Posterior Levator Advancement With Minimal Superior Tarsectomy. Ophthalmic Plast Reconstr Surg 2021; 37:86-90. [PMID: 32675719 DOI: 10.1097/iop.0000000000001772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To report the surgical technique and outcomes for adjustable ptosis correction using a posterior levator advancement with minimal superior tarsectomy. METHODS A retrospective single-center study was conducted on patients who underwent adjustable ptosis repair via posterior levator advancement with minimal superior tarsectomy by a single surgeon from 2002 to 2018. Patients with greater than 1 mm asymmetry between eyes or contour abnormalities underwent nonsurgical adjustment in the office within 6 days of surgery. RESULTS A total of 79 patients (146 eyelids) were included in this study. The patients were female (67%), underwent bilateral surgery (87%) with mean age of 63 years (range, 20-92). The mean improvement in marginal reflex distance 1 at postoperative month 1 was 2.56 ± 1.04 mm (p ≤ 0.0001). Postoperative symmetry of 1 mm or less between eyes was achieved in 96.6% of patients. Only 8 eyes (5.4%) underwent in-office adjustment postoperatively. No demographic or clinical differences were noted in eyes that required adjustments. Postoperative complications included dry eyes that resolved by 3 months (13.6%), suture cyst (1.4%), corneal abrasion (1.4%), and persistent eyelid edema (1.4%). Surgical revision was required in 2.8% of eyes. CONCLUSIONS The adjustable posterior levator advancement with minimal superior tarsectomy is an effective surgical technique for ptosis repair with the added benefit of in-office adjustability to correct minor asymmetries.
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Cohen LM, Rootman DB. Blepharoptosis Repair: External Versus Posterior Approach Surgery: Why I Select One over the Other. Facial Plast Surg Clin North Am 2021; 29:195-208. [PMID: 33906756 DOI: 10.1016/j.fsc.2021.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Ptosis surgery is performed via an anterior/external or posterior/internal approach, primarily defined by the eyelid elevator muscle surgically addressed: the levator complex anteriorly or Muller muscle posteriorly. Posterior ptosis surgery via Muller muscle conjunctival resection is an excellent first choice for cases of mild to moderate ptosis with good levator function, as it is predictable, provides a reliable cosmetic outcome, requires no patient cooperation during surgery, portends a lower rate of reoperation, and rarely leads to lagophthalmos and/or eyelid retraction postoperatively. External levator resection is preferred in patients with severe ocular surface/cicatricial conjunctival disease, shortened fornices, and lesser levator function.
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Affiliation(s)
- Liza M Cohen
- Division of Orbital and Ophthalmic Plastic Surgery, Doheny and Stein Eye Institutes, University of California Los Angeles, Los Angeles, 300 Stein Plaza, Los Angeles, CA 90095, USA
| | - Daniel B Rootman
- Division of Orbital and Ophthalmic Plastic Surgery, Doheny and Stein Eye Institutes, University of California Los Angeles, Los Angeles, 300 Stein Plaza, Los Angeles, CA 90095, USA.
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Yeh SH, Liao SL, Wei YH. Efficacy and predictability of Muller's muscle-conjunctival resection with different tarsectomy lengths for unilateral blepharoptosis treatment. BMC Ophthalmol 2021; 21:83. [PMID: 33579223 PMCID: PMC7881611 DOI: 10.1186/s12886-021-01849-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate the efficacy and predictability of Muller's muscle-conjunctival resection (MMCR) with different lengths of tarsectomy for the treatment of unilateral mild-to-moderate blepharoptosis. METHODS A retrospective study of patients who underwent MMCR with tarsectomy for unilateral mild-to-moderate blepharoptosis between January 2016 and December 2019 was performed. Individuals with adequate photographic documentation and good levator function were included. Data on age, gender, surgical designs, pre-operative and post-operative marginal reflex distance 1 (MRD1) and tarsal platform show (TPS), and complications were retrieved. RESULTS Sixty patients underwent 8-mm MMCR with 1- or 2-mm tarsectomy; 53 patients (88.3%) showed postoperative symmetry of MRD1 within 1 mm. The average postoperative improvement in MRD1 was 2.15 ± 0.8 mm. Thirty-two patients received 8-mm MMCR with 1-mm tarsectomy (group 1), and 28 patients underwent 8-mm MMCR with 2-mm tarsectomy (group 2). In group 1, postoperative symmetry rate was 90.6%, and the mean elevation of MRD1 was 1.66 ± 0.6 mm. In group 2, postoperative symmetry rate was 85.7%, and the mean elevation of MRD1 was 2.72 ± 0.6 mm. Both groups showed postoperative symmetry of TPS and significant improvement in eyelid position (p < 0.0001). No postoperative complication was noted, and no secondary surgery was needed. CONCLUSIONS MMCR with tarsectomy was proven to be a safe, rapid, and effective method for patients with mild-to-moderate ptosis. Predictability and symmetry of the outcome were statistically confirmed. We further suggest a 2.1-mm expected MRD1 elevation as a cut point for choosing between 1- or 2-mm tarsectomy.
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Affiliation(s)
- So-Hung Yeh
- College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shu-Lang Liao
- Department of Ophthalmology, National Taiwan University Hospital, 12F, No.7, Chung Shan S. Rd., Zhongzheng Dist., Taipei, Taiwan.,Department of Ophthalmology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yi-Hsuan Wei
- Department of Ophthalmology, National Taiwan University Hospital, 12F, No.7, Chung Shan S. Rd., Zhongzheng Dist., Taipei, Taiwan.
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Mangan MS, Ocak SY, Vural ET, Yildiz E. Müller Muscle-conjunctival Resection with or without Tarsectomy and Combined with Bandage Contact Lens Use in Ptosis Patients with Corneal Graft. KOREAN JOURNAL OF OPHTHALMOLOGY 2021; 35:10-17. [PMID: 33307624 PMCID: PMC7904405 DOI: 10.3341/kjo.2020.0119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 10/29/2020] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Mehmet Serhat Mangan
- Division of Ophthalmic Plastic and Reconstructive Surgery, Sadik Eratik Eye Clinic, Haydarpasa Numune Education and Research Hospital, University of Health Sciences, Istanbul,
Turkey
| | - Serap Yurttaser Ocak
- Division of Cornea, Department of Ophthalmology, Okmeydani Education and Research Hospital, University of Health Sciences, Istanbul,
Turkey
| | - Ece Turan Vural
- Division of Cornea, Sadik Eratik Eye Clinic, Haydarpasa Numune Education and Research Hospital, University of Health Sciences, Istanbul,
Turkey
| | - Elvin Yildiz
- Division of Cornea, Sadik Eratik Eye Clinic, Haydarpasa Numune Education and Research Hospital, University of Health Sciences, Istanbul,
Turkey
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Ghodke A, Mims MM, Shockley WW, Clark JM. Suture Knot Externalization Modification of the Fasanella-Servat Technique for Involutional Ptosis. Laryngoscope 2020; 131:1492-1496. [PMID: 33300616 DOI: 10.1002/lary.29294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/13/2020] [Accepted: 11/19/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Ameer Ghodke
- Department of Otolaryngology - Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, University of North Carolina, Chapel Hill, North Carolina, U.S.A
| | - Mark M Mims
- Department of Otolaryngology - Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, University of North Carolina, Chapel Hill, North Carolina, U.S.A
| | - William W Shockley
- Department of Otolaryngology - Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, University of North Carolina, Chapel Hill, North Carolina, U.S.A
| | - J Madison Clark
- Department of Otolaryngology - Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, University of North Carolina, Chapel Hill, North Carolina, U.S.A
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Nacaroglu SA, Karabulut GO, Fazil K, Serefoglu Cabuk K, Kandemir Besek N, Taskapili M. Comparing the outcome of Muller's muscle conjunctival resection for mild/moderate versus severe involutional aponeurotic ptosis. Eur J Ophthalmol 2020; 31:3436-3441. [PMID: 33118399 DOI: 10.1177/1120672120963454] [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: 11/16/2022]
Abstract
AIMS To compare predictability of the outcomes of Muller's muscle conjunctiva resection (MMCR) in patients with severe versus mild/moderate involutional aponeurotic ptosis. METHODS This was a retrospective case-control study. All cases were recruited into the groups in terms of preoperative marginal reflex distance of upper eyelid (MRD-1). Group 1 consisted of patients with mild to moderate blepharoptosis was defined as an MRD-1 equal to 1.1 to 3 mm and Group 2 consisted of patients with severe blepharoptosis defined as MRD-1 ⩽ 1 mm. All patients underwent MMCR based on the response to phenylephrine and the amount of ptosis. MRD-1 obtained both manually and with ImageJ analysis program preoperatively and on the postoperative sixth month was compared. Successful surgical outcome criteria were defined as MRD-1 ⩾ 2.5 mm and inter-eyelid symmetry ⩽ 1 mm. RESULTS A total of 97 eyes of 83 participants met the inclusion criteria for this study (Group 1 n = 50, Group 2 n = 47). In terms of MRD-1 success rates were 88% in Group 1, and 70.2% in Group 2 (p = 0.03). Preoperative MRD-1 which was measured by ImageJ, and the amount of resected tissue in mm were the predictive data of surgical outcome by the logistic regression analysis (OR 6.45, 95% CI 1.82-22.78, p = 0.004, OR 2.47, 95% CI 1.05-5.80, p = 0.037, respectively). CONCLUSION The surgical success of MMCR can be predicted via tissue resection length and preoperative MRD-1. Higher surgical success rates were obtained in cases with mild-moderate ptosis and clinically acceptable success rates were obtained in cases with severe ptosis.
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Affiliation(s)
| | | | - Korhan Fazil
- Istanbul Beyoglu Eye Research and Training Hospital, Istanbul, Turkey
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Putthirangsiwong B, Yang M, Rootman DB. Surgical outcomes following Muller Muscle-Conjunctival Resection in patients with glaucoma filtering surgery. Orbit 2020; 39:331-335. [PMID: 31809630 DOI: 10.1080/01676830.2019.1700283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/25/2019] [Indexed: 06/10/2023]
Abstract
PURPOSE Muller muscle-conjunctiva resection (MMCR) has been often considered to be relatively contraindicated in patients with previous glaucoma surgery. We investigate the glaucoma and ptosis outcomes in patients with glaucoma filtering blebs undergoing MMCR surgery. METHODS Retrospective cross-sectional case-control study at a single institution over a 15-year period on eyes of patients > 18 years of age who underwent MMCR surgery were included. Eyes were separated into 2 groups: 1) Ptosis with glaucoma filtering bleb(s) (case group); 2) Ptosis without a glaucoma filtering bleb (control group). The primary outcome measure was bleb failure. Secondary outcome measures were postoperative marginal reflex distance (MRD)1 and change in MRD1. RESULTS 87 eyes from 80 patients met the inclusion criteria, with 29 eyes from 25 patients in the case group and 58 eyes from 55 patients in the control group. The mean (SD) length of MMCR follow-up and glaucoma follow-up after MMCR surgery were 7.3 (15.2) months and 16.4(9.3) respectively. Preoperatively, there were no significant differences between groups in terms of mean (SD) age [73 (13.2) vs 73.4 (13.1) years; p = .79] nor preoperative MRD1 [1.3 (0.2) vs. 1.4 (0.1) mm; p = .90]. There were no bleb-related complications. Three eyes (10.3%) were characterized as postoperative bleb failure. No significant differences in mean postoperative MRD1 nor mean change in MRD1 were noted (p= .34 and p = .15). CONCLUSIONS Muller muscle-conjunctiva resection (MMCR) is an apparently safe and effective tool for the management of ptosis in patients with glaucoma filtering blebs.
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Affiliation(s)
- Bunyada Putthirangsiwong
- Division of Orbital and Oculoplastic Surgery, Stein Eye Institute, University of California , Los Angeles, California, USA
- Department of Ophthalmology, Ramathibodi Hospital, Mahidol University , Bangkok, Thailand
| | - Michael Yang
- Division of Orbital and Oculoplastic Surgery, Stein Eye Institute, University of California , Los Angeles, California, USA
| | - Daniel B Rootman
- Division of Orbital and Oculoplastic Surgery, Stein and Doheny Eye Institutes, University of California, Los Angeles , Los Angeles, California, USA
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Sweeney AR, Dermarkarian CR, Williams KJ, Allen RC, Yen MT. Outcomes After Müller Muscle Conjunctival Resection Versus External Levator Advancement in Severe Involutional Blepharoptosis. Am J Ophthalmol 2020; 217:182-188. [PMID: 32387434 DOI: 10.1016/j.ajo.2020.04.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE To compare outcomes between Müller muscle conjunctival resection (MMCR) ptosis repair and external levator resection (ELR) in patients with severe involutional blepharoptosis. DESIGN Retrospective, interventional, comparative case series. METHODS A retrospective review was performed of patients who underwent ptosis repair between 2012 and 2019. Inclusion criteria were patients who underwent MMCR or ELR ptosis repair, patients with complete documentation of preoperative eyelid measurements, and patients with documentation of postoperative outcome. The main outcome measure was surgical failure, defined as patient-reported or physician-reported dissatisfaction with postoperative eyelid height or postoperative upper margin reflex distance (MRD1) of less than 2 mm. Severe ptosis was described as an MRD1 of 0 or worse. Outcome analysis was also performed after stratification for concomitant blepharoplasty performed at the time of ptosis repair. RESULTS A total of 231 patients (372 eyelids) met the study criteria, of which 142 eyelids had severe ptosis. Comparing outcomes of MMCR vs ELR in patients with severe ptosis, there was a statistically significant higher rate of success after MMCR (P = .0143). The rate of ptosis repair success in eyelids that underwent MMCR was 97.2% and 90.9% in patients with severe ptosis and mild/moderate ptosis, respectively (P = .42). In eyelids that underwent ELR, the rate of ptosis repair success was 77.4% and 85% in eyelids with severe ptosis and mild/moderate ptosis, respectively (P = .15). Concomitant blepharoplasty did not affect ptosis repair outcomes in any group. CONCLUSIONS MMCR ptosis repair is an effective approach in treating patients with severe ptosis, and it may offer superior outcomes to ELR. In patients with good responses to phenylephrine, MMCR may offer an efficient and highly efficacious surgery regardless of presenting MRD1.
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Affiliation(s)
- Adam R Sweeney
- Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, USA
| | | | - Katherine J Williams
- Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, USA
| | - Richard C Allen
- Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, USA
| | - Michael T Yen
- Department of Ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, USA.
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Strategies of upper blepharoplasty in aging patients with involutional ptosis. Arch Plast Surg 2020; 47:290-296. [PMID: 32718105 PMCID: PMC7398815 DOI: 10.5999/aps.2020.01361] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/12/2020] [Indexed: 11/08/2022] Open
Abstract
In many aging individuals, dermatochalasis and involutional ptosis appear together. Therefore, for functional and aesthetic purposes, ptosis correction and upper blepharoplasty are performed together. The aim of this article is to investigate factors that should be considered in order to achieve good results when simultaneously performing involutional ptosis correction and upper blepharoplasty in aging patients. Involutional ptosis is usually corrected through aponeurosis advancement in mild cases. In moderate or severe ptosis, the Muller muscle and aponeurosis are used together to correct ptosis. Using the two muscles together has the advantages of reducing lagophthalmos and increasing the predictability of outcomes after surgery. Broadly speaking, the surgical method used for involutional ptosis varies depending on the specific case, but unlike congenital ptosis, it is often not necessary to perform overcorrection. In particular, if there are problems such as severe dry-eye symptoms or risk of lagophthalmos, undercorrection should be considered. When performing ptosis correction, the surgeon should be careful not to overdo skin excision; instead, limited excision should be performed. After ptosis surgery, the brow may descend and the double fold may look too small. However, in order to make the double eyelids look larger, the surgeon should consider making the double eyelid design high rather than excising an excessive amount of skin. In some cases, to obtain more natural double eyelids and favorable results, it may be necessary to perform a sub-brow lift or forehead lift before or after involutional ptosis surgery.
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Müller Muscle Conjunctiva Resection for Revision of Residual Ptosis After External Levator Advancement Surgery. Ophthalmic Plast Reconstr Surg 2020; 36:458-462. [DOI: 10.1097/iop.0000000000001594] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Müller's Muscle-conjunctival Resection Combined With Tarsectomy for Treatment of Congenital Ptosis. Ophthalmic Plast Reconstr Surg 2020; 35:619-622. [PMID: 31162300 DOI: 10.1097/iop.0000000000001410] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the efficacy of Müller's muscle-conjunctival resection combined with tarsectomy for the treatment of congenital ptosis. METHODS A retrospective, noncomparative case series was performed on 38 eyes of 36 patients who underwent Müller's muscle-conjunctival resection combined with tarsectomy for the treatment of congenital ptosis. Age range was 2-25 years (mean: 7.86 years). Follow-up measurements taken up to 4 years after procedure were compared with baseline values. RESULTS Thirty-six patients presenting with congenital ptosis underwent Müller's muscle-conjunctival resection combined with tarsectomy. All patients had fair-to-good levator function of 5-10 mm. A mean improvement in the margin reflex distance-1 of 2.79 mm (p value < 0.0001) was noted. All cases except one achieved excellent lid height and postoperative symmetry of the eyelids. CONCLUSIONS Müller's muscle-conjunctival resection combined with tarsectomy is a safe and effective procedure in the treatment of congenital ptosis in patients with moderate-to-good levator function. The surgery is rapid with quick recovery time. No complications were noted.The authors describe a retrospective case analysis of patients who underwent Müller's muscle-conjunctival resection combined with tarsectomy, for the treatment of congenital ptosis with moderate-to-good levator function, demonstrates excellent results.
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Abstract
PURPOSE Müller's muscle-conjunctival resection (MMCR) is a well-known approach for ptosis repair. In its standard fashion, it involves resection of Müller's muscle and conjunctiva, followed by suturing of the conjunctiva and Müller's muscle to the tarsus with absorbable or nonabsorbable sutures. The authors herein present their experience in performing MMCR without sutures. METHODS The study was conducted as a retrospective review of 19 patients (34 eyelids) undergoing sutureless MMCR. Thirty-three eyelids had acquired ptosis and 1 eyelid had congenital ptosis. Surgery consisted of a standard approach and placement of a Putterman clamp. Following excision of the clamped tissues, no internal sutures were placed. Preoperative and postoperative upper margin-to-reflex distances were measured and patients were evaluated for symmetry within 1 mm and the incidence of any complications. RESULTS Nineteen patients underwent 34 sutureless MMCR procedures. Of these, 13 patients had bilateral ptosis repair. Thirty-three of 34 eyelids (97%) showed improvement in margin-to-reflex distances, with an average improvement of 1.4 mm (range, 0-3.5 mm, SD = 0.64) among all patients. Eighteen of the 19 patients (94.7%) showed postoperative symmetry of margin-to-reflex distances within 1 mm (p < 0.001, χ test). One patient who underwent unilateral surgery demonstrated a Herring's response postoperatively, leading to the single case of asymmetry. There was 1 case of corneal abrasion seen postoperatively. CONCLUSIONS The sutureless technique is a rapid and effective method for performing MMCR. This technique is especially useful as an adjunct to blepharoplasty where mild ptosis exists for an added rejuvenating effect. It is low-risk and potentially corneoprotective when compared to the standard suture technique. Further studies could determine if a modified algorithm needs to be applied.
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Paap MK, Silkiss RZ. Improvements in Muller’s Muscle Resection Through the Use of Tenotomy Scissors and Dissolvable Suture. ACTA ACUST UNITED AC 2019. [DOI: 10.1177/0748806819885252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Muller’s muscle resection is a straightforward and effective surgical treatment for acquired blepharoptosis. The authors describe a novel modification of this procedure that reduces risk of corneal complications using dissolvable suture and tenotomy scissors in place of scalpel excision. In all, 122 consecutive adult patients with mild to moderate acquired eyelid ptosis treated with this modified technique were identified through chart review. In this cohort, all patients were satisfied with the result, none required reoperation, and none sustained postoperative complications. This technique modification maintains procedural efficacy and efficiency while improving patient comfort and decreasing the risk of inadvertently cutting a suture and inducing a corneal abrasion or incision dehiscence.
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Abstract
PURPOSE OF REVIEW To review recent advances on the mechanisms and management of acquired aponeurotic blepharoptosis. RECENT FINDINGS Recent advances over the past year have focused on refining well known methods of ptosis repair, expanding and modifying techniques to treat difficult and more severe conditions, and uncovering the biomechanical and neurostimulatory mechanisms of ptosis and its repair. SUMMARY Innovations in ptosis repair are discussed in the context of current treatment paradigms.
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Closed Posterior Levator Advancement in Severe Ptosis. Plast Reconstr Surg Glob Open 2018; 6:e1781. [PMID: 29922563 PMCID: PMC5999440 DOI: 10.1097/gox.0000000000001781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 03/20/2018] [Indexed: 11/25/2022]
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