The Impact of Hering’s Law in Blepharoptosis: Literature Review

Effect of Muller's muscle-conjunctival resection on the upper eyelid crease position in Asian eyelids: a retrospective cohort study

Purpose

Investigating the effect of Muller’s muscle-conjunctival resection (MMCR) on the eyelid crease position.

Methods

This retrospective study included patients with unilateral acquired blepharoptosis who underwent MMCR during October 2018–December 2021. The following factors were recorded: preoperative, after phenylephrine, postoperative marginal reflex distance1 (MRD1) and tarsal platform show (TPS) of bilateral eyelids. The primary outcome was to measure the change in TPS and evaluate the factors associated with post-operative TPS. The secondary outcomes included exploring the rate of MRD1 and TPS symmetry after the operation.

Results

Forty patients were included in the final analysis. The mean MRD1 of the ptotic eye was 1.28 ± 0.78 mm, 2.79 ± 0.66 mm and 3.20 ± 0.67 mm before, after phenylephrine and after the operation, respectively. The mean TPS of the ptotic eye was 5.90 ± 1.86 mm, 3.96 ± 1.49 mm and 2.79 ± 1.63 mm before, after phenylephrine and after the operation, respectively. Changes in mean TPS after the phenylephrine test and post-operation were statistically significant (p < 0.001). The linear regression model revealed that the absolute change in TPS after phenylephrine drop and absolute change in MRD1 post-operation were significantly correlated with the absolute change in TPS post-operation. Besides, the ratio of symmetry in MRD1 and TPS was greatly improved post-operation (82.5% and 70.0% respectively).

Conclusion

MMCR is an effective surgical method for ptosis correction as it can not only correct the eyelid crease position but also narrow the wide TPS. This method is particularly beneficial to patients with both mild to moderate ptosis and an asymmetric crease height.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02605-6.

Conjoint Fascial Sheath Suspension for Severe Blepharoptosis through Palpebral Margin Incision

BACKGROUND

Conjoint fascial sheath suspension can achieve pleasing surgical efficacy and dynamic eyelid movement in the treatment of severe ptosis. In recent years, the palpebral margin incision technique has been applied for double-eyelid blepharoplasty, which is characterized by inconspicuous scarring, short convalescence, and natural-looking outcome. However, studies of the application of this technique in the treatment of ptosis are scarce. This article aims to evaluate the efficacy and safety of conjoint fascial sheath suspension for treating severe blepharoptosis through palpebral margin incision.

METHODS

From March 2019 to January 2021, 32 patients (37 eyelids) underwent treatment with the modified technique. Preoperatively, levator muscle function and margin reflex distance 1 were documented. Correction effects, symmetry results, and complications were also evaluated postoperatively.

RESULTS

Adequate or normal correction was achieved in 33 eyelids (89.2%), and 31 patients (96.9%) obtained good or fair symmetry results. Common complications were undercorrection and conjunctival prolapse, which were both observed in four eyelids (10.8%), followed by overcorrection and hematoma.

CONCLUSIONS

The modified technique provides physical eyelid elevation and inconspicuous scarring and is effective for treating severe ptosis. Satisfactory functional and esthetic results could be obtained simultaneously without severe complications.

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 .

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.

Botulinum toxin-induced blepharoptosis: Anatomy, etiology, prevention, and therapeutic options

Background

Botulinum toxin A (BoNT‐A) has grown tremendously in aesthetic dermatology since 2002 when the United States Food and Drug Administration (FDA) first approved its use for treating moderate‐to‐severe glabellar lines. Blepharoptosis, due to local spread of toxin, is a reported side effect of BoNT‐A which, although rare, more frequently occurs among inexperienced practitioners.

Objectives

The purpose of this review is to highlight the causes and management of eyelid ptosis secondary to BoNT‐A administration including new anatomic pathways for BoNT‐A spread from the brow area to the levator palpebrae superioris muscle.

Methods

A literature search was conducted using electronic databases (PubMed, Science Direct, MEDLINE, Embase, CINAHL, EBSCO) regarding eyelid anatomy and the underlying pathogenesis, presentation, prevention, and treatment of eyelid ptosis secondary to BoNT‐A. Anatomic dissection has been performed to assess the role of neurovascular pedicles and supraorbital foramen anatomic variations.

Results

Blepharoptosis occurs due to weakness of the levator palpebrae superioris muscle. Mean onset is 3–14 days after injection and eventually self‐resolves after the paralytic effect of BoNT‐A wanes. Administration of medications, such as oxymetazoline hydrochloride or apraclonidine hydrochloride eye drops, anticholinesterase agents, or transdermal BoNT‐A injections to the pre‐tarsal orbicularis, can at least partially reverse eyelid ptosis. Anatomic study shows that a supraorbital foramen may be present in some patients and constitutes a shortcut from the brow area directly into the orbital roof, following the supraorbital neurovascular pedicle.

Conclusion

Providers should understand the anatomy and be aware of the causes and treatment for blepharoptosis when injecting BoNT‐A for the reduction of facial wrinkles. Thorough anatomic knowledge of the supraorbital area and orbital roof is paramount to preventing incorrect injection into “danger zones,” which increase the risk of eyelid ptosis.

Influence of epinephrine contained in local anesthetics on upper eyelid height in transconjunctival blepharoptosis surgery

PURPOSE

To examine the influence of epinephrine contained in local anesthetic on upper eyelid height in transconjunctival aponeurotic repair for aponeurotic blepharoptosis.

METHODS

This retrospective study included 164 eyelids from 94 patients with aponeurotic blepharoptosis. Patients were divided according to the use of local anesthetic with (group A, n = 108) or without 1:100000 epinephrine (group B, n = 56). Margin reflex distance-1 (MRD-1) was measured before and after local anesthesia, and before, during, and 3 months after surgery. Change in MRD-1_a (∆MRD-1_a) was calculated by subtracting the postanesthetic MRD-1 value from the preanesthetic value, and we defined ∆MRD-1_b by subtracting the postoperative 3-month MRD-1 value from the intraoperative value.

RESULTS

∆MRD-1_a was positive in group A (0.57 ± 0.63 mm) and negative in group B (- 0.50 ± 0.45 mm; p < 0.001). Postoperative MRD-1 decreased significantly from intraoperative MRD-1 in group A (P < 0.001), although there was no significant difference between intraoperative and postoperative MRD-1 in group B (p = 0.255). The magnitude of ∆MRD-1_b in group A (- 0.86 ± 0.63) was larger than that in group B (- 0.23 ± 0.26; p < 0.001).

CONCLUSIONS

Epinephrine stimulates Müller's muscle during surgery, which leads to postoperative upper eyelid droop after the disappearance of the epinephrine effect. Using local anesthetics without epinephrine may allow more accurate estimation of postoperative eyelid height in transconjunctival aponeurotic repair.

Minimally Invasive Conjoint Fascial Sheath Suspension for Blepharoptosis Correction

BACKGROUND

Blepharoptosis can not only affect facial appearance but physical and mental health as well. Traditional treatments require long recovery time and leave unpleasant scars. In this study, we explored a simple and effective way to correct mild, moderate blepharoptosis and analyzed the causes and precautions for postoperative complications.

METHODS

From March 2014 to May 2017, patients presenting with mild or moderate bilateral or unilateral blepharoptosis underwent minimally invasive blepharoptosis correction using suspension of the conjoint fascial sheath of the levator and superior rectus. Mild blepharoptosis was corrected by 1 or 2 of loops suspension sutures, whereas moderate blepharoptosis was corrected by 3 or 5 loops. The postoperative evaluation, including the degree of correction or residual ptosis, asymmetry and presence of lagophthalmos, was performed after a minimum follow-up period of 9 months.

RESULTS

Forty patients (55 eyelids) were included. The mean followed up period was 13.40 ± 4.60 months. Good results were seen in 48 ptosis eyes (87.27%). Double eyelid crease was formed simultaneously without an obvious wound. Two mild ptosis eyelids received a fair result, and 4 moderate ptosis eyelids improved to "mild ptosis." The mean marginal reflex distance 1 significantly increased postoperatively.

CONCLUSION

Long-term follow-up indicates that minimally invasive conjoint fascial sheath suspension works well for mild and moderate ptosis. With its short recovery time, simultaneous double eyelid crease formation and long-lasting effect, the surgery is worth popularizing.

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 .

Contralateral Mueller's muscle-conjunctiva resection: a therapeutic option in thyroid eye disease patients with unilateral eyelid retraction

Purpose: To evaluate pre- and post-operative marginal reflex distance 1 (MRD1) when conducting Mueller's muscle-conjunctiva resection (MMCR) on the normal eyelid of thyroid eye disease (TED) patients with unilateral eyelid retraction.Methods: This was a retrospective non-comparative case series. Medical records of TED patients with unilateral eyelid retraction, who underwent a contralateral MMCR from November 2015 to September 2017, were reviewed. Standard photographs of pre-operative, post-phenylephrine test and post-operative were measured for eyelid positions including MRD1, MRD2 and inter-palpebral fissure width. MMCR was indicated on the contralateral eyelid only in patients who had a cosmetically acceptable result from phenylephrine test and were willing to receive the operation on the normal eye.Results: Twelve TED patients who underwent MMCR on the normal eyelid were included in the study. Mean pre-operative MRD1 of retracted and normal eyelid were 5.7 mm (SD = 0.86) and 3.5 mm (SD = 0.65), respectively. Mean post-operative MRD1 of retracted and normal eyelid were 4.4 mm (SD = 0.76) and 4.1 mm (SD = 0.46), respectively. The asymmetry of MRD1 between eyes was significantly decreased from 2.1 mm (inter-quartile range (IQR) = 1.5-2.9 mm) pre-operatively to 0.3 mm (IQR = 0.1-0.7 mm) post-operatively (p = .002). None of these patients needed further eyelid correction surgery and there was no complication.Conclusions: In TED patients with unilateral eyelid retraction, using phenylephrine test on their normal eyes should be initiated. If eyelid position was satisfactorily equalized, performing MMCR on the normal eyelid is considered an effective alternative treatment with a predictable outcome.

Retrospective Analysis of the Effect of Hering's Law on Outcomes of Surgical Correction of Ptosis

INTRODUCTION

Several factors may influence aesthetic outcomes of ptosis surgery, especially in patients with asymmetrical ptosis. We retrospectively assessed the effect of Hering's law on surgical outcomes of patients with asymmetrical ptosis.

METHODS

Patients with mild to moderate asymmetrical ptosis (N = 300) who underwent advancement or plication of upper eyelid aponeurosis between January 2014 and July 2016 were enrolled. Fifty patients (group A) underwent surgery without taking into consideration the impact of Hering's law. Of these, 35 patients with unilateral ptosis (subgroup A1) underwent standard surgery on the contralateral side, whereas 15 patients with bilateral ptosis (subgroup A2) were first operated on the milder side followed by the more severely affected side.In 250 patients (group B), surgery was performed taking cognizance of the implications of Hering's law. These included 100 patients with unilateral ptosis (B1) and 150 with bilateral ptosis (B2). Difference in bilateral palpebral fissure symmetry by less than 0.5 mm was considered as satisfactory outcome.

RESULTS

Duration of postoperative follow-up ranged from 3 to 24 months. Satisfactory outcomes were achieved over 60% of patients in group A (A1, 60.6%; A2, 66.67%) and in 96% of patients in group B (B1, 95%; B2, 96.67%). Patients with unsatisfactory outcomes underwent repair according to Hering's law after 3 months and obtained good results.

CONCLUSIONS

Application of Hering's law may improve outcomes of corrective surgery in patients with asymmetric ptosis.

Therapeutic Algorithm for Congenital Ptosis Repair with Levator Resection and Frontalis Suspension: Results and Literature Review

BACKGROUND

Several treatments have been described for the treatment of congenital ptosis, but there are few studies that analyze the effectiveness of a therapeutic approach rather than a single technique.

AIMS

In this study, we aim to evaluate the effectiveness of our therapeutic algorithm, which relies on levator muscle resection and frontalis suspension with silicone rods, polytetrafluoroethylene (PTFE), or autologous fascia lata.

METHODS

We retrospectively analyzed all patients affected by congenital ptosis who underwent corrective surgery at a single department between January 1998 and January 2016.

RESULTS

A total of 116 procedures were performed in 86 patients, accounting for 35 levator resections, 67 frontalis suspensions, and 14 revisions. A satisfactory result was observed in 65 cases after one procedure (75.6%). Complications occurred in 13 cases after primary surgery (15.1%). Ptosis relapse was observed in 25 cases after primary procedure (21.5%). Frontalis suspension displayed a higher number of complications than levator resection (22.2% vs 3.1%, p=0.02).

CONCLUSION

Our therapeutic algorithm was effective in 75.6% after one procedure. Frontalis suspension procedures encountered a higher rate of complication than levator resection. Fascia lata should be preferred to silicon rods whenever possible due to the lower recurrence rate. These issues confirm the therapeutic algorithm, although larger prospective studies are necessary to validate our approach.

Factors Associated With Surgical Outcomes in Congenital Ptosis: A 10-Year Study of 319 Cases

PURPOSE

To evaluate the 10-year results of surgery for congenital ptosis and identify factors associated with excellent outcomes and recurrence.

DESIGN

Retrospective, interventional case series.

METHODS

A retrospective analysis was conducted of 319 patients who underwent surgical correction at a tertiary medical center for congenital ptosis. The main outcome measures were postoperative surgical outcomes and recurrence rates. Excellent lid height was assessed as a marginal reflex distance (MRD) greater than 3 mm. Recurrence was defined as a lid height less than 50% of the initial postoperative lid height.

RESULTS

The overall surgical success rate was 97.2%. On multivariate analysis, 3 factors were significantly associated with a greater probability of achieving excellent lid height: treatment using levator muscle resection (LMR) (adjusted odds ratio [OR], 1.76; P = .04), better preoperative MRD (adjusted OR, 2.21; P < .001), and absence of Marcus Gunn (jaw-winking) syndrome (adjusted OR, 0.12; P = .01). For recurrence, 7 significant risk factors were identified: children less than 1 year old (adjusted OR, 4.92; P = .02), poorer preoperative MRD (adjusted OR, 0.64; P = .04), poorer postoperative MRD (adjusted OR, 0.32; P < .001), treatment with frontalis suspension (FS) (adjusted OR, 5.86; P < .001), wound infection (adjusted OR, 9.45; P = .02), postoperative entropion (adjusted OR, 11.25; P = .003), and conjunctival prolapse (adjusted OR, 7.10; P = .03). Kaplan-Meier analysis showed that the 1-, 5-, and 10-year recurrence-free rates were 97.3% ± 1.2%, 80.5% ± 4.4%, and 76.7% ± 5.6%, respectively, for the LMR group and 90.9% ± 3.1%, 42.9% ± 8.1%, and 20.8% ± 10.1%, respectively, for the FS group (P < .001, log-rank test).

CONCLUSIONS

Surgical treatment of congenital ptosis had a high success rate. Identifying the risk factors and taking appropriate measures may result in better surgical outcomes and less recurrence. Our retrospective study showed that the likelihood of achieving excellent outcomes with lower recurrence rates was higher with LMR than with FS. However, a prospective randomized study is necessary to clarify their efficacy.

Effect of upgaze on lower eyelid position in Korean patients with congenital ptosis

PURPOSE

The purpose of this study was to demonstrate accompanying clinical features besides lid droop in congenital ptosis and to determine the effect of upgaze on lower eyelid position in patients with congenital ptosis.

METHODS

Pediatric patients with congenital ptosis who visited our clinic over a 1-month period in 2014 were recruited for this study. Clinical photographs and measurements were taken prospectively in primary gaze and upgaze. Measurements taken from photographs and clinical records include inferior scleral show (ISS), vertical lower lid height (LL), and canthal tilt angle (CTA).

RESULTS

There were 35 patients with congenital ptosis. There was more ISS in unilateral ptosis eyes than in the normal side in both primary gaze (p < 0.05) and upgaze (p < 0.01), with corresponding increase in ISS in upgaze (p < 0.05). There was also more ISS in unilateral ptosis eyes than in bilateral ptosis eyes in primary gaze (p < 0.05) and upgaze (p < 0.01), with accompanying increase in ISS in upgaze (p < 0.01). There was less elevation of the lower lid in unilateral ptosis eyes (0.5 ± 0.7 mm) than in the contralateral normal eyes (0.8 ± 0.7 mm) in upgaze, but this was not statistically significant (p = 0.07). CTA was lower in ptosis eyes than in normal eyes in primary gaze and upgaze (p < 0.01 and p < 0.05, respectively).

CONCLUSION

ISS was larger in ptosis eyes and upgaze appears to increase ISS. Canthal tilt is lower in congenital ptosis eyes than in normal eyes in primary gaze and upgaze.