Blepharophimosis-ptosis-epicanthus inversus syndrome (BPES)

Improvement of 1-Stage Comprehensive Operation Technique for Blepharophimosis-Ptosis-Epicanthus Inversus Syndrome

BACKGROUND

This retrospective case series presents the clinical results of a modified 1-stage comprehensive surgical method for blepharophimosis-ptosis-epicanthus inversus syndrome (BPES).

METHODS

A total of 25 patients with BPES underwent a modified reverse Z-plastic surgery method to bisect the epicanthus into 2 unequal V-shaped flaps and suture them alternately. The medial canthus ligament was partially incised, shortened, and sutured; the outer canthus was opened with a V-Y flap. The gray line of the outer canthus was cut to extend the eyelid margin length. Ptosis was corrected using the orbicularis oculi-frontalis composite flap technique. We studied the inner intercanthal distance (IICD), interpupillary distance (IPD), horizontal palpebral fissure length (HPFL), marginal reflex distance 1 (MRD-1), IICD/IPD ratio, IICD/HPFL ratio, Vancouver Scar Scale, and overall postoperative satisfaction.

RESULTS

The 25 patients included 12 girls and 13 boys (mean age, 8.3 ± 6.8 years), 19 of whom had a family history of BPES. The mean IPD value was 50.15 ± 7.43 mm. IICD decreased from 39.38 ± 2.39 mm preoperatively to 31.64 ± 2.37 mm postoperatively, IICD/IPD from 0.8 ± 0.1 preoperatively to 0.6 ± 0.1 postoperatively ( P < 0.05), and IICD/HPFL from 1.98 ± 0.33 preoperatively to 1.22 ± 0.10 postoperatively ( P < 0.01). HPFL increased from 20.08 ± 3.53 mm preoperatively to 26.04 ± 1.36 mm postoperatively ( P < 0.01), and MRD-1 from -1.12 ± 0.71 mm preoperatively to 3.24 ± 0.47 mm postoperatively ( P < 0.01). The postoperative Vancouver Scar Scale score was 3.68 ± 1.07. Patient satisfaction was rated as 8.8 ± 1.08, with a relatively high overall satisfaction rate.

CONCLUSIONS

The corrective effect on BPES was noticeable, improving the IICD/HPFL and IICD/IPD ratios. Postoperative scars were not evident, and patient satisfaction was high.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The Genetic and Clinical Features of FOXL2-Related Blepharophimosis, Ptosis and Epicanthus Inversus Syndrome

Blepharophimosis, ptosis, and epicanthus inversus syndrome (BPES) is a craniofacial disorder caused by heterozygous variants of the forkhead box L2 (FOXL2) gene. It shows autosomal dominant inheritance but can also occur sporadically. Depending on the mutation, two phenotypic subtypes have been described, both involving the same craniofacial features: type I, which is associated with premature ovarian failure (POF), and type II, which has no systemic features. The genotype-phenotype correlation is not fully understood, but it has been hypothesised that type I BPES involves more severe loss of function variants spanning the whole gene. Type II BPES has been linked to frameshift mutations that result in elongation of the protein rather than complete loss of function. A mutational hotspot has been identified within the poly-alanine domain, although the exact function of this region is still unknown. However, the BPES subtype cannot be determined genetically, necessitating informed genetic counselling and careful discussion of family planning advice in view of the associated POF particularly as the patient may still be a child. Following puberty, female patients should be referred for ovarian reserve and response assessment. Oculofacial features can be managed with surgical intervention and regular monitoring to prevent amblyopia.

Surgical Outcome of Epicanthus and Telecanthus Correction by Double Z-Plasty and Trans-Nasal Fixation with Prolene Suture in Blepharophimosis Syndrome

INTRODUCTION

Blepharophimosis Syndrome (BPES) is a complex and rare disease characterized by epicanthus inversus, telecanthus, lateral ectropion, narrowed or shortened inter-palpebral fissure distance and ptosis. It is mostly bilateral and may or may not be symmetrical. It is typically inherited as an autosomal dominant trait. In sporadic cases, the disease may occur without a prior family history as a genetic mutation from a deletion or translocation of the FOXL₂ gene, which maps to chromosome 3q23. Surgical treatment of this disease poses an oculoplastic challenge due to multiple complex eyelid deformities.

AIM

To evaluate the functional and cosmetic outcome of telecanthus and epicanthus correction by a Mustarde's rectangular double Z-Plasty and trans-nasal fixation using 1-0 prolene suture in BPES.

MATERIALS AND METHODS

This was prospective, interventional study of 16 patients over a period of three years. In this study, all patients had BPES with prominent epicanthus and telecanthus. Mustarde's double Z-plasty and trans-nasal fixation with 1-0 prolene suture was performed in the first of a two-stage operation. If ectropion was present, the lateral ectropion was corrected by a base-out flap transfer from the upper eyelid to the lower eyelid. After three months, a 2^nd stage was undertaken, involving a lateral canthoplasty for horizontal widening of a short palpebral fissure and a tarso frontalis sling with silicone rod for correction of moderate to severe ptosis. Patients were followed up for six months to one year with postoperative ophthalmologic examinations and photographs.

RESULTS

Out of 16 patients, 10 were females and six were males. All the patients had bilateral involvement. In this study preoperative Inner Intercanthal Distance (IICD) ranged from 38 mm to 42 mm and the mean IICD was 41.2±0.57 mm. Postoperative IICD ranged from 31 mm to 34 mm. Horizontal Palpebral Fissure Length (HPFL) ranged from 20 mm to 23 mm and the mean value of HPFL was 21.50 mm preoperatively. Postoperative HPFL ranged from 26 mm to 29 mm and had a mean value of 28.50 mm, which was much improved after a combined correction of telecanthus and lateral canthoplasty. The mean preoperative IICD and HPFL ratio was 1.77 and was reduced to a postoperative value of 1.2. The Marginal Reflex Distance1 (MRD-1) test value improved from +1.25 mm to +3.50 mm postoperatively after placement of a tarsofrontalis sling with silicone rod using the Fox's Pentagon technique. In this study, two eyes had minimal unequal correction but were cosmetically and functionally acceptable. Correction of IICD is possible up to 6 mm. No major complication e.g., CSF rhinorrhea was noted in this series and preoperative prominent epicanthal folds were abolished.

CONCLUSION

Here we propose a two-staged procedure involving a combined Mustarde's double Z-plasty with transnasal fixation using a 1-0 prolene suture with a flap transfer from the upper lid to the lower lid in the first stage and a lateral canthoplasty with a tarsofrontalis sling and silicone rod in the second stage. This technique is effective to correct epicanthus, telecanthus, ptosis and lateral ectropion in BPES with good cosmetic and functional outcome.

One-stage correction of blepharophimosis-ptosis-epicanthus inversus syndrome using a frontalis muscle transfer technique

Blepharophimosis-ptosis-epicanthus inversus (BPES) is a rare genetic disease involving a complex eyelid malformation. The surgical treatment approach for BPES is highly complex and a subject of controversy. This study reports the results of a one-stage frontalis muscle transfer technique to correct BPES. This retrospective, interventional study included 21 patients with BPES who had been followed-up for a minimum of 1 year. The one-stage intervention was a combination of three surgical techniques: Mustardé medial canthoplasty, Fox lateral canthoplasty, and the frontalis muscle transfer technique. Preoperative and postoperative measurements of the horizontal lid fissure length (HLFL), vertical lid fissure width (VLFW), inner intercanthal distance (IICD), and the IICD/HLFL ratio were analyzed by Wilcoxon's signed rank test. The mean preoperative measurements were 4.73 ± 0.32 mm for VLFW, 19.98 ± 3.74 mm for HLFL, 40.85 ± 4.46 mm for IICD, and 2.11 ± 0.45 mm for the IICD/HLFL ratio. The mean postoperative measurements were 7.86 ± 0.41 mm for VLFW, 24.47 ± 3.35 mm for HLFL, 32.52 ± 4.16 mm for IICD, and 1.35 ± 0.22 mm for the IICD/HLFL ratio (p < 0.0001 for all preoperative vs postoperative values). Postoperative complications included eyelid fold deformities, lagophthalmos, and conspicuous scars. Most of these complications gradually resolved. One-stage correction of BPES is safe and efficient with the surgical techniques described.

FOXL2 gene mutations and blepharophimosis-ptosis-epicanthus inversus syndrome (BPES): a novel mutation detected in a Chinese family and a statistic model for summarizing previous reported records

Previous studies found that the forkhead transcription factor 2 (FOXL2) gene mutations are responsible for both types of blepharophimosis-ptosis-epicanthus inversus syndrome (BPES) but have not established any systematic statistic model for the complex and even contradictory results about genotype-phenotype correlations between them. This study is aimed to find possible mutations of FOXL2 gene in a Chinese family with type II BPES by using DNA sequencing and to further clarify genotype-phenotype correlations between FOXL2 mutations and BPES by using a systematic statistical method, namely Multifactor Dimensionality Reduction (MDR). A novel mutation (g.933_965dup) which could result in an expansion of the polyalanine (polyAla) tract was detected in all patients of this family. MDR analysis for intragenic mutations of FOXL2 gene reported in previous BPES studies indicated that the mutations which led to much stronger disturbance of amino acid sequence were responsible for more type I BPES, while other kinds of mutation were responsible for more type II BPES. In conclusion, the present study found a novel FOXL2 gene mutation in a Chinese BPES family and a new general genotype-phenotype correlation tendency between FOXL2 intragenic mutations and BPES, both of which expanded the knowledge about FOXL2 gene and BPES.

Multistage correction of blepharophimosis: our rationale for 18 cases

BACKGROUND

Due to the complexity of staging order and the number of surgical procedures required to correct blepharophimosis-ptosis-epicanthus inversus (BPES), this study aimed to analyze multistage correction of BPES syndrome objectively.

METHODS

This retrospective study was undertaken with 18 BPES patients who underwent multistage correction from April 2004 to September 2007. Data regarding levator function, horizontal palpebral fissure length (HPFL), vertical interpalpebral fissure height (IPFH), inner intercanthal distance (IICD), and the ratio of IICD to HPFL were recorded and analyzed. Facial photographs were taken both pre- and postoperatively. Any complications were documented.

RESULTS

The Mustardé method was used for 13 patients, and the Y-to-V technique was selected for 5 patients. In addition, seven patients also received lateral canthoplasty. All the patients underwent frontalis aponeurosis suspension. Changes in both IICD and HPFL were statistically significant (P < 0.001). The IPFH also showed statistically significant improvement after surgery. The range in the preoperative ratio of IICD to HPFL was 1.48-2.35 (mean, 2.04 +/- 0.28). Postoperatively, the ratios for all the patients were less than 1.8 (range, 1.1-1.5; mean, 1.28 +/- 0.13). Changes in the ratio of IICD to HPFL were statistically significant (P < 0.001). Mild undercorrection was observed in two patients postoperatively. Although neither keratitis nor overcorrection occurred, conjunctiva prolapse was experienced by one patient 10 days after frontalis aponeurosis suspension.

CONCLUSION

Staged surgery for correction of BPES syndrome is beneficial in terms of improved function and cosmesis.