Blepharoptosis

Quantitative analysis of the eyelid curvature in patients with blepharoptosis

BACKGROUND

The aim of this study was to evaluate the ability of two novel eyelid curvature measurements to distinguish between normal eyes and different severities of blepharoptosis.

METHODS

A comparative cross-sectional analysis of upper eyelid curvature was performed for different severities of patients with unilateral blepharoptosis (congenital and aponeurotic) and normal controls. Mean upper lid contour index (ULCI) and area circularity index (ACI) were calculated for each group by dividing the intercanthal distance by upper eyelid margin length (ULCI) and dividing the interpalpebral area by the area of a circle enclosing the eye (ACI). The ratio of each index for the study and fellow normal eye of each patient was also calculated and compared between groups.

RESULTS

A total of 106 eyes including 30 eyes in the control group and 25, 27, and 24 eyes in the mild, moderate, and severe ptosis groups were enrolled in the study. ULCI and ACI showed a statistically significant difference between the groups (p < 0.001, p < 0.001). The inter-eye ratio (ULCI-ratio and ACI-ratio) of indices was also significantly different between groups (p = 0.002, p < 0.001). Pairwise comparisons revealed that ACI and ACI-ratio were significantly different between all pairs of study groups.

CONCLUSION

The results of our study showed that ACI based on area measurements may distinguish blepharoptosis patients from normal controls and from each other. Including the data from the fellow normal eyes in the form of ratio indices may improve the differentiating power. These results can be useful in designing the optimal eyelid curvature measurements.

Safety and Pitfalls of Blepharoptosis Surgery in Elderly People

Background  Elderly patients often have complications of blepharoptosis surgery that can result in the appearance or exacerbation of superficial punctate keratopathy (SPK). However, postoperative changes to SPK status have not been previously reported. We used subjective assessment of symptoms and measurement of SPK scale classification to investigate the safety and efficacy of blepharoptosis surgery in elderly patients. Methods  Included in this prospective study were 22 patients (44 eyes) with bilateral blepharoptosis that underwent surgery. Patients comprised 8 males and 14 females with a mean (±standard deviation) age of 75.7 ± 8.2 years (range: 61-89). Blepharoptosis surgery consisted of transcutaneous levator advancement and blepharoplasty including resection of soft tissue (skin, subcutaneous tissue, and the orbicularis oculi muscle). Margin reflex distance-1 (MRD-1) measurement, a questionnaire survey of symptoms and SPK scale classification, was administered preoperatively and 3 months postoperatively for evaluation. Results  The median MRD-1 was 1 mm preoperatively and 2.5 mm postoperatively, representing a significant postoperative improvement. SPK area and density scores were found to increase when the MRD-1 increase was more than 2.5 mm with surgery. All 10 items on the questionnaire tended have increased scores after surgery, and significant differences were observed in 7 items (poor visibility, ocular fatigue, heavy eyelid, foreign body sensation, difficulty in focusing, headaches, and stiff shoulders). Conclusion  Blepharoptosis surgery was found to be a safe and effective way to maintain the increase in MRD-1 within 2.0 mm. Despite the benefits, surgeons must nonetheless be aware that blepharoptosis surgery is a delicate procedure in elderly people.

Sarcopenia as a potential risk factor for senile blepharoptosis: Nationwide Surveys (KNHANES 2008–2011)

As the world’s population is aging, sarcopenia is recognized as essential to assess people’s lifelong condition and do appropriate early intervention. Senile blepharoptosis is also a problem in old age deteriorating visual function and causing a cosmetic decline. We investigated the association between sarcopenia and the prevalence of senile blepharoptosis, using a nationwide representative survey in Korea. A total of 11,533 participants were recruited. We used the body mass index (BMI)- adjusted appendicular skeletal muscle (ASM) definition as the muscle mass index (MMI, ASM [kg] divided by BMI [kg/m2]). The association between blepharoptosis prevalence and MMI was analyzed using multivariate logistic regression. Sarcopenia, defined as the lowest MMI quintile group in both men and women, was also associated with the prevalence of blepharoptosis (ORs 1.92, 95% CI 1.17–2.16; p < 0.001). These associations remained statistically significant after adjusting for various factors related to blepharoptosis using multivariate analysis (ORs 1.18, 95% CI 1.04–1.34; p = 0.012). Moreover, MMI was found to have a proportional relationship with eyelid lifting force (levator function), which is closely related to the occurrence and severity of ptosis. Sarcopenia is related to the prevalence of senile blepharoptosis, and patients with lower MMI were more likely to have blepharoptosis. These results suggest that sarcopenia can affect visual function and aesthetics.

Oxymetazoline Hydrochloride Eye-Drops as Treatment for Myasthenia Gravis-Related Ptosis: A Description of Two Cases

In this article, we described two patients with myasthenia gravis-related ptosis who experienced sustained improvement with the use of oxymetazoline hydrochloride ophthalmic solution 0.1%. Despite the commonly used treatments for ptosis in myasthenia gravis (MG), such as acetylcholinesterase inhibitors and corticosteroids, complete remission of ptosis is not always achieved, and these treatments are often accompanied by systemic side effects. Our case report suggests the long-term efficacy of daily use of oxymetazoline eye drops in improving ptosis, providing a potential alternative or adjunctive treatment option without significant adverse effects. Further research is necessary to confirm these observations across larger cohorts of MG patients and establish the effectiveness of oxymetazoline eye drops in MG-related ptosis.

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.

A Modified Approach to Transconjunctival Levator Advancement Offering Intraoperative Options

BACKGROUND

The transconjunctival technique is an effective approach to mild to moderate blepharoptosis repair that does not involve skin incision. However, accurate surgical manipulation of this method is greatly restricted by poor intraoperative evaluation.

OBJECTIVES

The aim of this study was to introduce a modified transconjunctival approach with flexible intraoperative adjustments in order to achieve more accurate ptosis correction.

METHODS

Taking a transconjunctival approach, the levator aponeurosis and Müller's muscle were folded with a square-like mattress suture for flexible adjustment and accurate correction.

RESULTS

In 18 mild ptosis eyelids, 94.5% (17 eyelids) achieved adequate or normal correction. In 9 eyelids with moderate ptosis, 88.9% (8 eyelids) achieved adequate or normal correction. Of 24 ptosis patients, 23 (95.8%) achieved a good or fair symmetry result.

CONCLUSIONS

This study presents a modified transconjunctival technique for repair of mild to moderate ptosis, which is characterized by flexible intraoperative adjustments that produce satisfying functional and aesthetic outcomes.

LEVEL OF EVIDENCE: 4

Optical Quality Assessment in Patients with Unilateral Congenital Ptosis: A Matched Case-Control Study

Background. To evaluate the differences in the corneal higher-order aberrations (HOAs) and optical quality of the ptosis eyes compared with the normal fellow eyes in the unilateral congenital ptosis patients. Methods. A matched case-control study was performed in 17 pairs of eyes in 17 unilateral congenital ptosis patients. The ptosis eye was enrolled in the ptosis group while the normal fellow eye was enrolled in the normal group. The HOAs obtained from Pentacam HR and the optical quality parameters obtained from Optical Quality Analysis System (OQAS) were compared between the two groups. Results. There were significant differences in a vertical coma and vertical trefoil on the anterior corneal surface between the ptosis group and the normal group $\left(p<0.05\right)$ . The OQAS parameters in the ptosis group were significantly different from those in the normal group $\left(p<0.05\right)$ . The vertical fissure height (VFH) showed a significant correlation with the total HOAs, 3rd HOAs, and vertical coma on the anterior corneal surface $\left(p<0.05\right)$ . Conclusions. Compared with the normal fellow eyes, the ptosis eyes showed significantly degraded optical quality. The eyelid position was important for the changes of corneal HOAs in the ptosis eyes. The reasons for the discrepancy of the OQAS parameters between the ptosis eyes and normal fellow eyes were multiple.

Decreased smooth muscle component in Müller's muscle may induce or aggravate blepharoptosis in elderly Asians

Previous studies have suggested that the senile ptosis is mostly aponeurotic ptosis. Aponeurotic ptosis, the most common cause of acquired ptosis in elderly adults, results from disinsertion or dehiscence of the levator aponeurosis from the tarsal plate. Müller's Muscle is located below the levator aponeurosis, and its main function is to contribute to a few millimeter in upper eyelid elevation. In recent years, studies have shown that Müller's Muscle plays a more important role in the eye-opening process than previously reported. There are few reports on the changes of smooth muscle component with age in Müller's Muscle. As far as we know, it has not been written up previously. Through histological study on Müller's Muscle of Chinese cadaver specimens, we found that Müller's Muscle contained obvious smooth muscle components above the upper edge of the tarsus in the specimen of a child. However, in elderly specimens, we observed that the smooth muscle components decreased gradually even faded away from originated inferior branch of levator superioris muscle to upper margin of tarsus. We hypothesized that the number of smooth muscle components in Müller's Muscle gradually decreases, with the increase of age, which further affects the function of Müller's Muscle in assisting levator muscle, and further causes or aggravates ptosis. Our hypothesis needs to be further verified by more autopsy histological studies of different ages and genders, so as to provide a new idea for the clinical diagnosis and treatment of ptosis.

Correlation between body composition and blepharoptosis in adults

BACKGROUND

The present study aimed to explore the association between body composition indices, such as fat mass (FM) and lean body mass (LBM), and blepharoptosis.

METHODS

The study evaluated 12,168 Korean adults aged 40 years or older using data from the Korea National Health and Nutrition Examination Survey (2008-2011). FM index (FMI, kg/m²) and LBM index (LBMI, kg/m²) were used to correct for the effects of body size. Multivariable logistic regression analysis was performed to investigate the association between blepharoptosis and body composition indices such as FMI, LBMI, and fat percentage of whole body or head. Stratified analyses were also performed by levator function.

RESULTS

Higher FMI and head fat percentage were significantly associated with blepharoptosis (adjusted odds ratio [aOR] = 1.35, 95% confidence interval [CI] = 1.10-1.65; and aOR = 1.32, 95% CI = 1.03-1.69 in the highest tertile compared with the lowest, respectively). In the subgroup with good levator function (≥8 mm), higher FMI, head fat percentage, and head lean mass were significantly associated with blepharoptosis (aOR for the right eye [aORr] = 1.42 and aOR for the left eye [aORl] = 1.36; aORr = 1.41 and aORl = 1.37; and aORr = 1.50 and aORl = 1.49 in the highest tertile compared with the lowest, respectively; all p < 0.05).

CONCLUSIONS

Body compositions with high adiposity indices, such as high FMI and head fat percentage, were positively associated with blepharoptosis. Awareness of the potential correlation between obesity-associated fat deposition and blepharoptosis could improve management of the condition and contribute to understanding the pathogenesis of blepharoptosis.

Clinical and Demographic Characteristics of Blepharoptosis in Korea: A 24-year Experience including 2,328 Patients

Purpose

To describe the demographics, relative incidence of subtypes, and clinical characteristics of blepharoptosis in Korean patients.

Methods

This is a retrospective, observational case series consisting of 2,328 patients who underwent ptosis surgery from 1991 to 2014 at a tertiary referral hospital in Korea. The patients were classified according to the type of ptosis and the evaluation of clinical characteristics including levator muscle function (LF) and degree of ptosis.

Results

Of the 2,328 patients, 1,815 (78%) had congenital ptosis and 513 (22%) had acquired ptosis. Simple congenital ptosis is the most common type overall (73.7%), and aponeurotic ptosis is the most common acquired type. More than three-quarters of eyes with congenital ptosis were affected in a moderate (34.4%) to severe degree (41.3%), and most of these eyes had fair (33.7%) to poor LF (60.1%). Among eyes with acquired ptosis, approximately three-quarters were affected in a mild (33.3%) to moderate degree (41.0%), with 63.3% of these eyes having good LF. The most widely used surgical technique was frontalis suspension (55.1%), followed by levator resection (29.0%) and aponeurosis repair (14.8%). At 3 years after the first surgery, 15.7% of patients with congenital ptosis and 10.4% of patients with acquired ptosis underwent reoperation.

Conclusions

Although the prevalence has decreased from previous years, the proportion of cases with congenital ptosis was higher in this study than has been shown in research conducted in the West. The majority of eyes with congenital ptosis was affected to a severe degree and had poor LF, while those with acquired ptosis were affected to a moderate degree and had good LF. More cases with acquired ptosis presented with fair to poor LF, and frontalis suspension surgery was performed more commonly compared to previous studies. The reoperation rate was higher in congenital ptosis compared to acquired ptosis.

Eyelid Retraction in Isolated Unilateral Congenital Blepharoptosis

Isolated unilateral congenital ptosis is encountered relatively infrequently in clinical practice. It typically consists of a unilateral droopy eyelid, weak levator palpebrae superioris muscle function, lid lag, and an absent upper lid crease with no other abnormalities on examination. We present a four-and-a-half-year-old girl with isolated and mild unilateral congenital ptosis who unexpectedly demonstrated a static upper eyelid on downgaze in conjunction with a well-formed upper lid skin crease. We attribute this uncommon sign in congenital ptosis to stiffness and presumed fibrosis of the levator muscle. Examining the function of the eyelids in all directions of gaze is important in patients with abnormalities of lid position, since additional useful information can be gleaned about the status of the levator muscle including, aberrant regeneration or fibrosis.

Analysis of the causes of recurrence after frontalis suspension using silicone rods for congenital ptosis

Background

Silicone rod is a commonly used synthetic suspension material in frontalis suspension surgery to correct blepharoptosis. The most challenging problem and a decisive drawback of the use of silicone rod is a considerable rate of ptosis recurrence after surgery. We examined patients with recurred ptosis and assessed the physical and micromorphological properties of implanted silicone rods to determine the causative mechanisms of recurred ptosis after frontalis suspension using silicone rod.

Methods

This is a prospective observational case series of 22 pediatric patients with recurred ptosis after frontalis suspension using silicone rods for congenital ptosis. Implanted silicone rods were observed and removed during the operation for correction of recurred ptosis. The removed silicone rods were physically and micromorphologically evaluated to determine the cause of recurrence.

Results

Pretarsal fixation positions migrated upward, whereas suprabrow fixation positions migrated downward during ptosis recurrence. The breaking strength of implanted silicone rods was reduced by approximately 50% during 3 years. Cracks, debris, and loss of homogenous structure with disintegration were observed on scanning electron micrographs of implanted silicone rods in patients with recurred ptosis. Preoperative severe degree of ptosis also contributed to recurred ptosis.

Conclusions

Recurrence of ptosis after frontalis suspension using silicone rod was associated with physical changes of implanted silicone rods, including positional migration, weakened tensile strength, and micromorphological changes in combination with patients’ characteristics.

The utility of margin-reflex distance in determining the type of surgical intervention for congenital blepharoptosis

Aims:

To evaluate the utility of margin-reflex distance (MRD) as an alternative to levator function (LF) in choosing the appropriate surgical procedure for congenital blepharoptosis.

Settings and Design:

This was a retrospective, observational study.

Subjects and Methods:

Records of patients with simple (dystrophic) congenital ptosis who were operated and followed for ≥6 months postoperatively and whose outcomes were deemed as successful were evaluated in the study. Success was defined as a MRD at the last postoperative visit of ≥3 mm. In all cases, levator resection was performed when LF was >4 mm and frontalis suspension when LF was ≤4 mm.

Statistical Analysis Used:

For statistical evaluations, LF was accepted as the gold standard parameter for deciding on the surgical intervention, and the optimum cutoff point for initial MRD was determined as the point at which sensitivity and specificity was highest at the receiving operating curve for the selection of surgical procedure.

Results:

Of one hundred and three eyes of ninety patients (44 female/46 male), levator resection was used in 44.7% and frontalis suspension in 55.3%. When the optimum cutoff point for MRD was determined as 0.5 mm, the sensitivity was 71%, specificity was 86%, and the area under the curve that represented the discriminative power of this parameter was found to be 0.826.

Conclusion:

The MRD at the cutoff point of 0.5 mm may be used as an alternative to LF to determine the type of surgical intervention in patients with congenital blepharoptosis whose LF cannot be reliably obtained in clinical evaluations.

Deep levator palpebrae superioris detachment during aponeurosis surgery via transcutaneous approach in ptosis correction

PURPOSE

To evaluate the efficacy of deep levator palpebrae superioris - Müller's muscle complex detachment from conjunctiva and other connective tissues in order to improve post operative lid opening and levator function for ptosis surgery via the transcutaneous approach.

METHODS

In this retrospective study, 23 patients (29 eyelids) were surgically treated for ptosis repair between 2003 and 2008. All surgery was performed by the same surgeon. Patients were divided into 2 groups. The first group (12 patients) consisted of patients who underwent deep levator dissection during surgery; the second group (11 patients), used as control group, consisted of patients treated without deep levator dissection. Postoperative lid opening was compared in the two groups using the Mann-Whitney non-parametric test.

RESULTS

The comparison between change in lid opening changes between the two groups was statistically significant (P<0.01).

CONCLUSIONS

Deep levator detachment can be included among standard surgical steps during ptosis surgery via transcutaneous approach in order to improve postoperative lid opening and levator function.