The factors influencing visual development in blepharophimosis-ptosis-epicanthus inversus syndrome

[Management of blepharophimosis, ptosis, epicanthus inversus syndrome at a referral center in Tunisia]

INTRODUCTION

Blepharophimosis ptosis epicanthus inversus syndrome (BPES) is a rare congenital hereditary abnormality. It includes complex orbital-palpebral malformations, causing aesthetic and functional ramifications. Management of BPES requires two steps : diagnosis and treatment.

PATIENTS AND METHODS

We performed a retrospective descriptive study of 44 patients (88 eyelids) with blepharophimosis-ptosis-epicanthus inversus syndrome (BPES). In our series, we opted for two-stage surgery in 28 cases : epicanthus-telecanthus surgery followed by ptosis surgery. Simultaneous surgery was performed in 5 cases.

RESULTS

The mean age at the first visit was 6 years (6.1±6.4). The mean age of our patients at the time of the first surgery was 6.6 years. Epicanthus surgery was performed in 35 cases. The two techniques used to correct epicanthus were Y-V plasty in 30 cases (85.7%, n=35) and Y-V+double Z plasty in 5 cases (14.3%, n=35). Correction of the telecanthus was performed at the same time by a medial canthal tendon plication in 31 cases (88.6%, n=35) or transnasal canthopexy in 4 cases (11.4%, n=35). The mean age at the time of ptosis surgery was 7.23 years (±6.25), ranging from 8 months to 27 years. Ptosis surgery was performed in 41 cases (79 eyelids), of which 3 patients underwent unilateral ptosis surgery due to asymmetrical ptosis. The techniques used were levator resection in 64 eyelids and frontal suspension in 15 eyelids.

CONCLUSION

BPES is often clinically diagnosed. The difficulty in management lies in the complex surgery required. There is no established consensus regarding surgical techniques or the timing of the surgeries.

A Novel Medial Canthal Reconstruction Technique in Children With Blepharophimosis Syndrome

PURPOSE

There are different techniques for medial canthoplasty in blepharophimosis syndrome where individuals have epicanthus inversus and telecanthus leading to typical facial appearances. These methods have potential problems with scarring, epistaxis, and extrusion of metal plates.

METHODS

The authors describe a novel technique of medial canthal reconstruction using titanium microplates with microscrew fixation to the anterior lacrimal crest, with effective, safe, and reproducible results.

RESULTS

Seven children with blepharophimosis syndrome underwent medial canthus reconstruction surgery at a single center with the collaboration of a pediatric oculoplastic surgeon and craniofacial plastic surgeon to improve eye opening through correction of the lid contours and telecanthus.

CONCLUSIONS

This is a safe, effective, and reproducible technique, with minimal morbidity and rapid postoperative recovery in children. It produces cosmetically acceptable scars and a strong stable reconstruction of the medial canthal insertion.

[Effectiveness of upper eyelid rotation flap via blepharoplasty incision for correction of mild to moderate epicanthus]

Objective

To evaluate an modified epicanthoplasty which can reduce epicanthic scar in blepharoplasty with mild to moderate epicanthus, by using upper eyelid rotation flap via blepharoplasty incision.

Methods

A clinical data of 34 patients with mild and moderate epicanthus (trial group), who were treated with blepharoplasty and epicanthoplasty by using upper eyelid rotation flap, between July 2016 and October 2017, was retrospectively analyzed. And 38 patients who were treated with blepharoplasty and epicanthoplasty by using traditional "Z" plastic method were recruited as control group. There was no significant difference in age and degree of epicanthus between 2 groups ( P>0.05). The lengths of palpebral fissure were measured at preoperation and at 6 days and 6 months after operation, and the length difference between pre- and post-operation was calculated to evaluate the improvement degree. The effectiveness was evaluated with reference to the scale of epicanthus orthopedics.

Results

All incisions of 2 groups healed by first intention, and all patients were followed up 6 months. The epicanthi of 2 groups were significantly corrected. The inner canthus of trial group had no incision; and there were scars at inner canthus of control group, with obvious hyperplasia in 6 cases. The improvement degree of the length of palpebral fissure in trial group and control group were 3.63%±0.07%, 3.70%±0.05% and 4.64%±0.09%, 4.46%±0.10% at 6 days and 6 months after operation, respectively. There was no significant difference between 2 groups ( t=0.005, P=0.996; t=0.287, P=0.871). The effectiveness was excellent in 20 cases, good in 12 cases, and poor in 2 cases in trial group, with an excellent and good rate of 94.12%; meanwhile, the effectiveness was excellent in 16 cases, good in 16 cases, and poor in 6 cases in control group, with an excellent and good rate of 84.21%. There was no significant difference between 2 groups ( χ ²=0.796, P=0.372).

Conclusion

The modified epicanthoplasty by using upper eyelid rotation flap via blepharoplasty incision can significantly reduce epicanthic scar with simple operation and satisfactory effectiveness.

Blepharophimosis, Ptosis, and Epicanthus Inversus Syndrome: Expanding the Phenotype

We present a 3-month-old girl who displayed typical clinical characteristics of blepharophimosis, ptosis, and epicanthus inversus syndrome (BPES). She was referred to our clinic with an initial diagnosis of Down syndrome. Clinical features of elevated follicle stimulating hormone and low estradiol levels in the case were diagnosed as BPES syndrome and were consistent with BPES type 2. To date, there are no cases of BPES with cleft palate and cardiomyopathy, suggesting that these novel findings can be part of this condition.

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.

Congenital alacrima in a patient with blepharophimosis syndrome

PURPOSE

To report a case of congenital alacrima in a patient with Blepharophimosis Syndrome (BPES).

METHODS

Case report of a 9-month-old female who presented with severe dry eyes. Further investigation revealed bilateral absence of lacrimal glands confirmed by CT. This unique case and its management are discussed.

RESULTS

Conservative management with artificial tears and ointment did not treat the ocular surface dryness. A combination of aggressive lubrication with surgical occlusion of the lower lid punctums was required to improve the corneal surface.

CONCLUSION

BPES can be associated with many ophthalmic and facial abnormalities. Review of the pubmed literature, reveals this is the first reported case of alacrima and BPES. Patient with alacrima have severe ocular surface dryness, which requires aggressive and life long lubrication and tear supplementation.