Sling for the sling: a new technique for long-term correction of severe congenital ptosis

INTRODUCTION

Severe congenital ptosis poses a complex challenge for oculoplastic surgeons, requiring meticulous surgical intervention to restore eyelid function and improve aesthetic outcomes mainly by using frontalis sling approach. A crucial issue in frontalis sling surgeries is the sustainability of effect.

PURPOSE

This retrospective study reports the outcomes of two surgical techniques for treating severe congenital ptosis in the paediatric age group: Silicon rods ptosis sling and a novel technique involving the use of Silicon rods with green braided polyester (Ethibond) sutures to secure the rods in place "sling for the sling".

METHODS

The medical records of children who underwent frontalis suspension were reviewed in a retrospective fashion. We identified two groups; the first group (20 patients: 35 eyelids) had the traditional frontalis suspension surgery using silicone suspension set, the second group (14 patients: 25 eyelids) was operated using the new "sling for sling" technique. We used the postoperative marginal reflex distance-1 (MRD-1) as the primary outcome measure while the frequency of both wound related complications and recurrence were considered as secondary outcome measures. Post operative data were collected and compared after 1 month, 6 months, 12 months, and 18 months.

RESULTS

Preliminary results indicate promising outcomes for both techniques, with significant improvement in eyelid elevation observed in both groups. However, the novel technique using Silicon rods with Ethibond sutures demonstrated enhanced sustainability, leading to a more durable outcome with significantly less recurrence.

CONCLUSION

This study highlights the potential benefits of the novel technique in treating severe congenital ptosis and introduces an innovative approach to Silicone rods fixation to achieve a long-term corrective effect.

Congenital ptosis with aponeurotic maldevelopment: clinical and surgical perspectives : Aponeurotic maldevelopment in congenital ptosis

PURPOSE

Levator muscle dystrophy has been commonly accused being the main pathology of congenital ptosis, nevertheless, few reports drew attention to the existence of congenital aponeurotic defects. This study aims at highlighting the detailed clinical and surgical features of aponeurotic maldevelopment together with the efficacy of simple aponeurosis repair.

METHODS

This is a retrospective nonrandomised study including patients with congenital ptosis who underwent levator muscle surgery throughout 4 years. Patients' records were reviewed for the preoperative clinical assessment and photographs, intraoperative recorded data, and videos as well as postoperative data and photographs.

RESULTS

Twenty-seven eyes of 22 patients (9.4%) out of 287 eyes were recorded to have absent levator muscle at its typical anatomical insertion site intraoperatively. The mean preoperative MRD1 was (0.44 ± 1.17 mm). The mean levator function was 8.56 ± 3.89 mm, with higher-than-normal crease position (mean value 10.07 ± 1.62 mm). 25 eyes of included cases (92.6%) showed total absence of the levator aponeurosis edge which only was revealed after cutting through the orbital septal covering of the preaponeurotic fat.

CONCLUSION

Congenital aponeurotic defect is an established yet under reported entity of congenital ptosis with reproducible characteristic intraoperative findings. Simple aponeurosis repair could achieve ptosis correction in such cases.

Outcomes of a novel algorithm for levator muscle plication surgery in congenital blepharoptosis

AIM

to assess the outcomes of a novel algorithm for the calculation of the amount levator muscle plication in congenital blepharoptosis surgery.

METHODS

this retrospective comparative study included 34 patients with congenital ptosis subjected to levator muscle plication surgery during the period from October 2021 to November 2022. They were divided into two groups. Group A: the amount of levator muscle plication was calculated by a traditional formula [(amount of ptosis x 3) + 9 mm in cases with good levator function or (amount of ptosis x 3) + 11 mm in cases with fair levator function]. Group B: the amount of levator muscle plication was calculated by a novel nomogram [the result of the traditional formula was modified by subtracting 4 mm if the calculated amount was ≥ 15 mm or subtracting 3 mm if the calculated amount was < 15 mm]. Demographic data, baseline ptosis characteristics and postoperative results at 1st week, 1st month, 3rd month and 6th month were compared between the groups. Primary outcome measure was postoperative Marginal Reflex Distance (MRD1). Secondary outcome measures were lid contour, lid crease and any reported complications.

RESULTS

Group A included 20 eyes of 18 patients while Group B included 20 eyes of 16 patients. The mean amount of levator muscle plication was 16.98 ± 2.44 mm and 13.48 ± 2.42 mm in group A and group B respectively. The difference between the two groups was highly statistically significant (p < 0.001). Mean MRD1 at the 1st postoperative week was 4.95 ± 0.37 mm in group A and 4.08 ± 0.64 mm in group B. This difference was highly statistically significant (P < 0.001). Overcorrection was seen in 8 (40%) eyes in group A and 1 (5%) eye in group B. The difference was statistically significant between the two groups (p = 0.008). Undercorrection was seen in only 1 (5%) eye in group B. No other complications were reported. Surgical success was achieved in 12 (60%) eyes in group A versus 18 (90%) eyes in group B. The difference between the two groups was statistically significant (p = 0.03).

CONCLUSION

our novel nomogram for the calculation of the amount levator muscle plication in congenital blepharoptosis surgery is effective in achieving a satisfactory postoperative MRD1.

A novel technique for small-incision levator resection with a double mattress suture for ptosis correction

PURPOSE

To introduce a novel technique for small-incision levator resection in ptosis surgery and evaluate its efficacy in a pilot study among patients affected by congenital or aponeurotic ptosis.

METHODS

We prospectively enrolled congenital and aponeurotic ptosis patients if their levator function was not poor (≥5 mm) from June 2021 through October 2022. Surgical technique involved a 1-cm lid crease incision, minimal dissection, and creating a loop passing through the tarsus and levator aponeurosis. Success was defined as postoperative MRD-1 ≥3 mm and inter-eyelid MRD-1 difference ≤1 mm. Eyelid contour quality was scored excellent, good, fair, and poor according to its curvature and symmetry.

RESULTS

Sixty-seven eyes (35 congenital and 32 aponeurotic) were included in the study. Mean age was 34±19 years (range, 5-79 years). Mean preoperative levator function and levator resection amount were 9.53 mm and 8.39 mm in the congenital group and 12.34 mm and 4.15 mm in the aponeurotic group, respectively. Mean pre- and postoperative MRD-1 was 1.61 mm and 3.27 mm respectively (P<0.001). The overall success rate was 82.1% (95% C.I: 71.7-89.8%); the result was failure in 12 cases, of which 11 had under-correction. Preoperative MRD-1 was correlated with a success rate (P=0.017).

CONCLUSION

The described technique shows non-inferior results to the previously described surgical methods and also it shows very good lid contour outcome and minimal lag. The findings suggest that the double mattress single suture technique can be used in both congenital and aponeurotic ptosis.

Surgical Interventions for Congenital Ptosis: a Systematic Review and Meta-analysis of 14 Randomized Controlled Trials

BACKGROUND

Several types of surgeries have been used in the treatment of congenital ptosis, but the optimal methods and materials for this treatment are unknown.

PURPOSE

The study aims to evaluate the comparative effectiveness and safety of various surgical methods and materials for treatment of congenital ptosis.

METHODS

We performed comprehensive searches of five databases, two clinical trial registries and one gray literature database from inception to January 2022 for related trials to include in this study. Meta-analysis was performed to evaluate the effect of surgical methods and materials on the primary outcomes: margin reflex distance 1 (MRD1), palpebral fissure height (PFH), and degree of lagophthalmos; and secondary outcomes: undercorrection, entropion, corneal epithelial defects, wound dehiscence, recurrence, infection, and cosmetic outcomes.

RESULTS

A total of 14 trials evaluating 909 eyes of 657 patients were included in our study. Compared with the levator plication, the frontalis sling significantly increased the MRD1 (MD = - 1.21; 95% CI [- 1.69, - 0.73]), and the levator resection significantly increased the PFH (MD = 1.30; 95% CI [0.27, 2.33]). For the frontalis sling surgical patterns, the fox pentagon was significantly better than the double triangle at improving the degree of lagophthalmos (MD = 0.70; 95% CI [0.32, 1.08]), while the opened pattern provided statistically better cosmetic outcome than the closed frontalis sling. Analysis of surgical material showed that absorbable sutures significantly increased the MRD1 (MD = 1.16; 95% CI [0.60, 1.72]) compared to non-absorbable sutures when used in levator plication; frontalis sling surgeries performed with silicon rods significantly increased the PFH (MD = 0.88; 95% CI [0.29, 1.47]) compared to those performed with Gore-Tex strips, while autogenous fascia lata provided statistically better aesthetic outcome for lid height symmetry and contour.

CONCLUSION

Different surgical methods and materials appear to affect different aspects of the congenital ptosis treatment outcome.

LEVEL OF EVIDENCE III

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 .

Congenital ptosis repair in children: comparison of frontalis muscle suspension surgery and levator muscle surgery

PURPOSE

Comparing the surgical and refractive outcomes of congenital ptosis repair by different surgical techniques.

METHODS

This longitudinal cohort study reviewed medical records of 101 patients who underwent congenital ptosis repair, from 2006 to 2022 in a single center. Analysis was performed for demographic background, co-morbidities, pre-operative and post-operative ocular examinations and refraction, complications, reoperations, and success rates.

RESULTS

Following exclusion criteria, we remained with 80 patients (103 eyes) who underwent either frontalis muscle suspension surgery (FMS) (55 eyes) or levator muscle surgery (LM) (48 eyes). Patients in the FMS group were younger (mean age of 3.1 vs. 6.0 years, p < 0.001) and had worse pre-operative ocular assessments including prevalence of visual axis involvement, chin-up head position, ptosis severity, and levator muscle function (LF) (p < 0.001). Both groups had a 25% rate of reoperation, however while in the LM group reoperation was required solely due to undercorrection, in the FMS group various indications prompted reoperation. Success rate was higher in the FMS group (87.3% vs. 60.4%, p = 0.002). While pre-operative astigmatism was higher in the LM group (p = 0.019), no significant differences were observed post-operatively. Spherical and spherical equivalent changes over time were significant only in the FMS group (p = 0.010 and p = 0.004, respectively).

CONCLUSIONS

Within our cohort, a higher success rate of congenital ptosis repair was observed among patients who underwent FMS compared to LM, despite similar reoperation rates. In cases of severe ptosis and moderate LF, LM demonstrated a lower-than-anticipated success rate. Astigmatic changes following ptosis repair were not consistent in either group.

Amblyopic astigmatism characteristics and surgical outcomes in younger children with severe congenital ptosis after frontalis suspension surgery

BACKGROUND

To examine the astigmatism characteristics and surgical outcomes in patients with unilateral severe congenital ptosis following frontalis suspension surgery.

METHODS

We included 53 congenital ptosis patients who underwent frontalis suspension surgery in Hunan Children's Hospital. Each patient underwent a refractive examination before and after surgery to assess astigmatism. We also evaluated the effects and complications associated with the procedure.

RESULTS

Degree of astigmatism in ptotic and fellow eyes was - 1.45 ± 0.59 D and - 0.66 ± 0.51 D before surgery. Ratio of severe astigmatism in ptotic and fellow eyes was 51.3 and 12.8%. The fellow eyes presented with with-the-rule astigmatism (WR; 71.8%) and against-the-rule astigmatism (AR; 20.5%) types, with no cases of oblique astigmatism (OA). Ptotic eyes demonstrated higher frequencies of AR (59.0%) and OA (10.2%) than did fellow eyes. Furthermore, the former showed increased astigmatism, followed by a gradual decrease at the 6-month, before significantly decreasing at the 1-year postoperatively. The ratio of postoperative AR and OA astigmatism cases in ptotic eyes decreased to 35.9 and 7.7% 1 month postoperatively. However, there was a postoperative increase in the WR ratio from 30.8 to 56.4% after 1 month. Kaplan-Meier survival analysis showed a success rate of 81.4% at 6 months and 62.9% at 12 months which was influenced by the following complications: suture reaction, epithelial keratopathy, infection and granuloma, lid lag, and recurrence.

CONCLUSION

Monocular congenital ptosis could develop severe astigmatism and higher frequency of AR or OA, early surgery may ameliorate astigmatic amblyopia.

Timing of Surgery and Treatment Options for Congenital Ptosis in Children: A Narrative Review of the Literature

Congenital ptosis has varying degrees of impact on the visual development or psychological health of a child depending on its severity. Some controversies and misconceptions remain regarding the management of congenital ptosis in children. Particularly, the accurate diagnosis of the severity of congenital ptosis in younger children, assessment of the visual developmental status of the child, optimal timing of surgery, and treatment choice are still issues in clinical practice that need to be explored. This report presents a comprehensive review of these aspects of the correction of congenital ptosis to provide a valuable reference for clinical practice. Our review shows that currently used surgical procedures for ptosis may result in over- or under-correction to varying degrees. The differences may be due to the physical condition and age of the child and the degree of cooperation during preoperative examination and assessment, resulting in inaccurate results. Alternatively, intraoperative swelling and bleeding may lead to errors in the values recorded by the surgeon. 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 .

Consanguinity and Increased Risk of Congenital Ptosis: A Case-Control Study from Southern Iran

Purpose

To assess consanguinity as a probable risk factor for congenital ptosis.

Methods

In this case-control study, 97 patients with congenital ptosis and 97 participants as the control group were included. The age, sex, and residence area of the control group were matched with the cases. The inbreeding coefficient (F) was calculated for each participant, and the mean of the inbreeding coefficient (α) was calculated for each group.

Results

The prevalence of consanguineous marriage in parents of cases with congenital ptosis and those of the control group was 54.6% and 30.9%, respectively (P < 0.002). The mean of the inbreeding coefficient (α) in patients with ptosis was 0.026, whereas it was 0.016 in the control group (T = 2.51, degree of freedom = 192, P = 0.0129).

Conclusions

The rate of consanguineous marriage was significantly higher among the parents of patients with congenital ptosis. It implies a probable recessive pattern in the etiology of congenital ptosis.

Evolution of the «frontal flap advancement» in congenital ptosis

The treatment of congenital ptosis with poor levator activity is often based upon the union of the superior eyelid to the frontalis muscle by using different materials as potential grafts. Nevertheless, theses grafts may lead some complications. In order to avoid them, a new technic has been described using an advancement flap of the frontalis muscle, that is tided to the upper tarsus, eliminating the need of a graft. Although, it is not yet a standard procedure, reason why many variants has been recently described with the objective of improve the aesthetical and functional results. The goal of this systematic review is to conscientiously evaluate these variants with the propose of determine which one gives the best results in terms of safety, functional and aesthetical outcomes. From the review of the published procedures, we conclude that the best technique in terms of functional and aesthetical results is: sub-orbicularis dissection via lid crease incision reaching the orbital margin, followed by blunt dissection of the frontalis muscle and creation of a "U" shaped flap (that might be associated to a levator advancement in severe cases), finally, the frontalis flap is stitched to the upper end of the tarsus taking care to maintain a symmetrical contour when compared to the contralateral eye. The final eyelid margin height should be 1.5 mm above the sclero-corneal limbus.

Surgical outcomes of tarsofrontalis sling surgery using silicon rod versus supramaximal levator resection in unilateral congenital ptosis with poor levator function

PURPOSE

To compare the surgical outcomes of tarsofrontalis sling surgery using silicon rod versus supramaximal levator resection in patients of unilateral congenital ptosis with poor levator function (≤ 4 mm).

MATERIALS AND METHODS

This randomized control study was conducted over a period of 18 months. 44 patients were enrolled in the study group. The study population was randomly divided into two groups (22 in each group). In Group A, congenital ptosis was treated with tarsofrontalis sling surgery using silicon rod and supramaximal levator resection was done in the group B. Follow-up examination was done at postoperative day 1, one week, 1 month, 6 months and 12 months. Surgical outcome measures were change in marginal reflex distance-1 (MRD 1), vertical palpebral fissure height (VPFH) and inter-eyelid difference of margin reflex distance 1 and complications in two groups.

RESULTS

The mean age of patients in group A was 7.25 ± 6.10 years ranging from 1-18 years and mean age of patients in group B was 5.64 ± 2.44 years ranging from 3 to 11 years. Good surgical outcome was obtained in 73-77% of both groups. MRD1and VPFH increased significantly after surgery from baseline in both the groups (p value < 0.001). Inter-eyelid MRD 1 difference also improved significantly in both groups following ptosis surgery.

CONCLUSION

Both supramaximal levator resection and tarsofrontalis sling surgery are equally effective in cases of unilateral ptosis patients with poor levator function and should be part of the surgical armamentarium for treating congenital ptosis.

Refractive error characteristics and influence on ocular parameters in patients with unilateral congenital ptosis

Background

The study aimed to investigate the difference in refractive status and ocular parameters between ptotic and fellow eyes in patients with unilateral congenital ptosis.

Methods

Thirty patients (53% males, age 22.00 ± 11.41 years) with unilateral congenital ptosis diagnosed and treated at the First Affiliated Hospital of Sun-yat Sen University were enrolled and underwent detailed refractive examinations from March 2019 to February 2022. Ocular biometric measurements were performed by an IOL Master 700 biometer. The differences in refractive error characteristics, best-corrected visual acuity (BCVA), and ocular parameters including axial length (AL), central corneal thickness (CCT), aqueous depth (AQD), anterior chamber depth (ACD), lens thickness (LT), and keratometry values between ptotic and fellow eyes were analysed.

Results

A lower BCVA (logMAR, median (IQR), 0.00 (− 0.13,0.00), P = 0.009) and a higher incidence of amblyopia (n (%), 7(23%), P = 0.016) were observed in ptotic eyes. The CCT of ptotic eyes was greater than that of fellow eyes (mean ± SD, 539.83 ± 26.73 μm, P < 0.001). The keratometry values at the flat axis (K1) and mean corneal power (Km) were smaller in ptotic eyes (mean ± SD, 42.11 ± 1.49 D, 42.68 ± 1.52 D, respectively, both P = 0.001). There was no significant difference in AL between ptotic and fellow eyes.

Conclusions

Congenital ptosis influences ocular parameters, mainly causing a thicker and flatter cornea. Patients with unilateral congenital ptosis might have lower BCVA in the ptotic eyes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02511-x.

Surgical correction of severe congenital ptosis using a modified frontalis muscle advancement technique: A single-arm trial

PURPOSE

To describe our experience with a modified frontal muscle advancement flap to treat patients with severe congenital ptosis.

METHODS

Analysis of the clinical charts of 154 patients who underwent a modified frontal muscle advancement flap. The FM was exposed by a crease incision. The FM flap was created by deep dissection between the orbicularis muscle and orbital septum from the skin crease incision to the supraorbital margin and subcutaneous dissection from the inferior margin of the eyebrow to 0.5 cm above the eyebrow. No vertical incision was made on the FM flap to ensure an intact flap wide enough to cover the entire upper tarsal plate. Contour, symmetry of height, marginal reflex distance (MRD1), and complications were assessed. Mean follow-up was 10 months.

RESULTS

The mean patient age was 7.6 ± 5.6 (range, 2-18) years. The mean MRD1 was 3.2 ± 1.3 mm after the operation. All bilateral cases achieved symmetry and optimal lid contour; 17 unilateral cases were under corrected, with a success rate of 89.0%. Complications such as entropion, exposure keratitis, FM paralysis, frontal hypoesthesia, severe haematoma, and entropion were not observed in our series.

CONCLUSION

A modified frontal muscle advancement flap produced a high success rate with a clear field of vision, mild trauma, and few complications. This technique is relatively simple and should be considered for correcting severe congenital ptosis.Date of registration: 29-03-2020Trial registration number: ChiCTR2000031364Registration site: http://www.chictr.org/.

Postoperative Visual Outcome: Sling procedure with prolene sutures in children with simple congenital ptosis

Objective:

To assess the visual outcome after sling procedure using prolene sutures in children with simple congenital ptosis.

Methods:

A descriptive case series study was performed in the Department of Ophthalmology of Jinnah Post Graduate Medical Centre, for a duration of six months in which 20 patients aged 3-10 years were selected with either unilateral or bilateral congenital ptosis. They were thoroughly examined and visual acuity and degree of ptosis were measured pre-operatively. Frontalis sling surgery was performed using prolene sutures on all patients after which their visual acuity and degree of ptosis were measured once again after three months post-operatively. Data were analyzed using SPSS version 20.0. For qualitative variables, frequency and percentages were calculated. Mean and Standard deviation was commutated for the quantitative variable.

Results:

The mean age of the patients was 8.15±1.75. 11 (55%) male and 9 (45%) female participants were included in the study. Visual acuity improved in all the patients with all the patients attaining a visual acuity of 6/6 (n=12, 60%), 6/9 (n=7, 35%), and 6/12 (n=1, 5%). The degree of ptosis post-operatively was not found in any patient either.

Conclusion:

Sling procedure helped in eliminating ptosis and improved visual acuity in patients with simple congenital ptosis.

Maximal levator resection versus Gore-Tex® sling for congenital blepharoptosis with poor levator function

BACKGROUND:

Treating congenital blepharoptosis is often mandatory to clear the visual access and avoid amblyopia; however, when the levator function is poor, achieving a satisfactory long-term outcome is challenging. This study aimed to compare the outcomes of maximal levator resection (MLR) with those of frontalis suspension (FS) using Gore-Tex ^®, in the treatment of congenital blepharoptosis with poor levator function.

PATIENTS AND METHODS:

The study included 102 eyelids of 66 patients of mean age 4.3 ± 1.6 standard deviation (SD) years, randomly divided into two groups (51 eyes each). Group A: FS using Gore-Tex ^®, Group B: MLR. Postoperative outcomes were evaluated at 1, 6 and 12 months. Patients' ophthalmic examination including margin-reflex distance (MRD1) before and after surgery and postoperative complications were recorded.

RESULTS:

At the end of the follow-up, the mean MRD1 increased from 0.3 ± 0.7 SD mm in Group A, 0.4 ± 0.8 SD mm in Group B preoperatively, to 2.7 ± 0.5 SD mm and 2.9 ± 0.7 SD mm, respectively (P < 0.001 in both groups). Results of Group B were significantly higher than Group A (P = 0.047). Success was achieved in 77 eyelids (75.4%), distributed as follows: 36 eyelids (70.6%) in Group A, and 41 eyelids (80.1%) in Group B. The total recurrence rate was 6.9% (seven eyes), while other complications were recorded in 23 eyes (22.5%).

CONCLUSION:

MLR, compared to FS with Gore-Tex^® sling, can be a more efficient surgical option to correct congenital blepharoptosis with poor levator excursion. Prominent postoperative lagophthalmos warrants close ocular surface observation in early follow-up weeks.

Hyperopic anisometropia with a shorter axial length ipsilateral to the ptotic eye in children with congenital ptosis

BACKGROUND

To investigate the clinical characteristics of children with congenital ptosis, with particular attention given to the incidence of anisometropia, and the difference in axial length (AL) between the right and left eyes.

METHODS

The medical charts of 55 patients with congenital ptosis at Niigata University Medical and Dental Hospital were retrospectively analyzed. Clinical characteristics, including age, cycloplegic refraction, AL, and the presence of amblyopia and its causes were analyzed.

RESULTS

Age at the initial visit was 16 ± 20 (mean ± standard deviation, the same applies below) months. Of the 49 patients whose cycloplegic refraction was measured, hyperopic anisometropia, defined as ≥ one-diopter difference in spherical equivalent (SE), was observed in 1/11, 9/27 and 5/11 patients with bilateral, right, and left ptosis, respectively. Among 14/38 patients with hyperopic anisometropia involving unilateral ptosis, 13 demonstrated a larger SE in the ptotic eye than in the non-ptotic eye. The inter-eye difference in AL (AL of the ptotic eye minus that of the non-ptotic eye) in six patients with unilateral ptosis and hyperopic anisometropia ipsilateral to the ptotic eye (-0.29 ± 0.40 mm) was significantly smaller than that in three patients with unilateral ptosis and no hyperopic anisometropia (0.38 ± 0.29 mm).

CONCLUSIONS

At our institute, children with congenital ptosis had a high incidence of hyperopic anisometropia ipsilateral to the ptotic eye. Furthermore, this condition was associated with a shorter axial length. These results indicate that refractive correction for hyperopic anisometropia is important for proper visual development in children with congenital ptosis.

Anterior approach levator plication for congenital ptosis, absorpable versus non absorpable sutures

PURPOSE

To compare the efficacy of two different suture types in levator plication for correction of congenital ptosis.

SUBJECTS AND METHODS

Prospective comparative interventional randomized study involving 42 eyes of 42 patients aged more than 6 years with congenital ptosis and good levator action. The exclusion criteria were as follows: bilateral ptosis, history of previous surgery, fair or poor levator action, and associated other ocular diseases. Patients were randomized into group A, in which double-armed 5/0 polyester Ethibond were used, and group B, in which double-armed 5/0 Coated Vicryl^® (polyglactin 910) suture material we used. Outcomes including eyelid height and stability of eyelid height over time were compared with follow-up data. The MRD was 4.05 ± 0.36 mm and 3.95 ± 0.34 after 1 week for both groups A and B, respectively. At the end of study follow up period (24 weeks), the MRD was 3.60 ± 0.42 mm in group A, and 2.52 ± 0.85 mm in group B.

CONCLUSION

No difference in eyelid height between two groups in early postoperative period, but the postoperative eyelid height was more stable over time in the 5/0 polyester Ethibond group (group A) than in the 5/0 Coated Vicryl^® (polyglactin 910) group (group B).

An Inflammatory Reaction to Stored Fascia Lata 37 Years Postimplantation

We report a rare case of a suspected inflammatory reaction to stored fascia lata 37 years post-placement. Clinical, imaging, histopathological, and immunohistochemical findings are presented, with a literature review on reactions to stored fascia lata. A 39-year-old woman had upper eyelid congenital ptosis repaired successfully at 2 years with bilateral frontalis suspension procedures using stored fascia lata. Thirty-seven years later, the patient presented with swelling of her eyelids and forehead, which was tender to the touch, in the same pattern as the fascia lata slings placed earlier. Histopathological examination disclosed a non-necrotizing granulomatous inflammatory infiltrate with numerous asteroid bodies. Initially, it was responsive to oral prednisone, but with recurrent inflammation, long-term methotrexate was required to control the inflammation. To our knowledge, this type of delayed inflammatory reaction has not been previously reported. It raises a concern about the use of allogeneic donor tissue and accepted sterilization techniques that may not be 100% effective in deactivating all components of the donor graft, including potential infectious pathogens, leading to a subsequent latent reaction.

[Treatment of congenital ptosis in a low-income country: polypropylene frontalis sling at the African Institute of Tropical Ophthalmology]

INTRODUCTION

Treatment of congenital ptosis is exclusively surgical; the frontalis sling method is most appropriate when the ptosis is severe, with no upper eyelid levator function. This surgery typically utilizes various materials (autologous fascia lata, silicone, nylon, or polypropylene bands, etc.).

MATERIALS AND METHODS

This was a retrospective descriptive study of 22 children under 16 years of age, treated for congenital ptosis by frontalis suspension of the levator muscle of the upper eyelid using the polypropylene technique, between January 1, 2014 and June 30, 2017 at the African Institute of Tropical Ophthalmology teaching hospital.

RESULTS

In our study, the surgical result (prior to correction of recurrences) was satisfactory in 81.82 % of cases, with a recurrence rate of 13.64 %. The mean follow-up was 14 months, ranging from 4 to 25 months.

DISCUSSION

The use of polypropylene provides encouraging results in ptosis surgery, while also offering the advantage of being low cost and more available. Its use in developing countries deserves special attention.

Malignant hyperthermia in a 4-year-old girl during anesthesia induction with sevoflurane and succinylcholine for congenital ptosis surgery

Malignant hyperthermia (MH) is a rare pharmacogenic disorder of skeletal muscle calcium regulation, resulting from general anesthesia that can be fatal. Most cases are caused by administration of volatile anesthetics or depolarizing muscle relaxants.

It has been generally reported that both of sevoflurane and succinylcholine can induce the delayed onset of MH.

Here, we report a case of malignant hyperthermia in a four-year-old girl during anesthesia induction for unilateral congenital ptosis surgery, two minutes after sevoflurane and succinylcholine administration. The crisis was atypical but early recognized and managed by administration of dantrolene with symptomatic treatment.

Factors related to amblyopia in congenital ptosis after frontalis sling surgery

Background

Amblyopia is a main concern in children undergoing frontalis sling surgery for repairing congenital ptosis. This study aimed to evaluate factors related to amblyopia in children undergoing frontalis sling surgery.

Methods

IRB-approved retrospective review of children under the age of 12 who received frontalis sling surgery. Preoperative demographic data, strabismus, margin reflex distance 1 (MRD1), lid fissure height, sling type, refraction errors, surgical outcome and amblyopia were evaluated.

Results

This study included 48 eyelid procedures performed in 38 patients. Median age was 4.0 years. Etiology was congenital ptosis in 42 eyes (87.5%) and blepharophimosis in 6 eyes (12.5%). Mersilene mesh was the sling material used in 36 eyes (75%), silicone in 6 eyes (12.5%), and polytetrafluoroethylene (PTFE) in 6 eyes (12.5%). Mean duration of follow-up was 27.8 ± 25.0 months (range, 3 to 128 months). Amblyopia was observed in 17 eyes (35.4%) at the final follow-up. Factors significantly associated with final amblyopia included blepharophimosis (p = 0.017), preoperative MRD1 ≤ − 1.0 mm (p = 0.038), preoperative lid fissure ≤4.5 mm (p = 0.035), preoperative anisometropia (spherical equivalent) (p = 0.011), and postoperative astigmatism (p = 0.026).

Conclusions

Study results suggest that blepharophimosis, preoperative MRD1 ≤ − 1.0 mm, preoperative lid fissure ≤4.5 mm, preoperative anisometropia (spherical equivalent), and postoperative astigmatism are associated with amblyopia after frontalis sling surgery in patients with congenital ptosis.

Surgical treatment of severe congenital ptosis using deep temporal fascia

Purpose: To evaluate the surgical outcome of a frontalis sling using deep temporal fascia in the treatment of severe congenital ptosis (SCP). Methods: A retrospective, interventional case series was performed. The study involved 25 patients with SCP (>4 mm). All patients underwent frontalis sling surgery with deep temporal fascia between 2004 and 2012 with a follow-up period of 12 months at a minimum. Data regarding eyelid position, eyelid symmetry, cosmetic outcomes, and postoperative complications were evaluated. Results: The mean age at surgery was 7.68 years (range 4-17 years) with an average follow-up of 60 months (range is 12-108 months). The functional success rate was 88% (22/25). Ptosis recurred in 8% (2/25) of patients, overcorrection was present in 4% (1/25) of patients. The patients with ptosis recurrence underwent reoperation. The preoperative margin-to-reflex distance (MRD1) was -0.85±0.87 mm (range, -2.5 to + 0.5 mm), while the postoperative MRD1 was + 2.1 ± 1.05 mm (range, -1.5 to + 4 mm) (p < .0001). Lid symmetry (asymmetry < of 1 mm of MRD1 between the two eyes) was present in all the successful cases. Postoperative complications included transient exposure keratopathy (32%) and inflammatory brow reaction (8%). Conclusions: Frontalis sling operation with deep fascia temporalis is very effective in the treatment of SCP with excellent long-term functional and cosmetic successes.

Surgical treatment of unilateral severe simple congenital ptosis

Unilateral congenital ptosis with poor levator function of ≤4 mm continues to be a difficult challenge for the oculoplastic surgeon. Surgical correction can be accomplished with unilateral frontalis suspension, maximal levator resection, or bilateral frontalis suspension with or without levator muscle excision of the normal eyelid. Bilateral frontalis suspension was proposed by Beard and Callahan to overcome the challenge of postoperative asymmetry, allowing symmetrical lagophthalmos on downgaze, postoperatively. However, most surgeons and patients prefer unilateral correction on the abnormal eyelid either with a frontalis suspension or maximal levator resection. Frontalis suspension may be performed through the various surgical techniques using different autogenous or exogenous materials. Autogenous fascia lata is considered the material of choice with low recurrence rates but carries the drawbacks of the difficulty of harvesting and postoperative morbidity from the second surgical site. Recent reports have suggested that maximal levator resection provides improved cosmesis, a more natural contour, and avoids brow scars. Although both treatments have shown to have similar success rates, there is much debate about what the most favorable method for treating severe unilateral ptosis. We review the literature on the various surgical treatments for unilateral severe congenital ptosis, including the rationale, advantages and disadvantages of each technique.

Long-Term Effects of Frontalis Fascial Slings on the Elastic Properties of the Upper Eyelid

PURPOSE

To measure the long-term effects of frontalis slings with fascial tissues on the downward eyelid saccadic movements Methods: Downward lid saccades for 10, 20, 30, 40, and 50 degrees of downgaze were measured in a sample of 19 patients with congenital ptosis who underwent frontalis slings with fascia lata (autogenous and banked) and temporalis fascia. Mean postoperative time was 10.7 years ± 3.8 SD. Seventeen age-matched normal subjects comprised the control group. Lid movements as well as the magnitude of brow motion were quantified in all participants with an opto-electronic device that automatically corrected any head movement.

RESULTS

Most patients (77.4%) displayed lagophthalmos on eyelid closure. The lid saccades of the patients were severely restricted and did not increase beyond 30 degrees of downgaze. The maximum velocity of lid saccades was also abnormally low. Although the pre- and postoperative lid positions did not differ between eyes operated with the three types of slings, interocular analysis of patients who had bilateral surgery showed that the restrictive effect on the saccadic movements was more asymmetrical with banked fascia than with autogenous tissue. Overall, there was a significant negative correlation between the surgical effect with frontalis contraction and maximum saccadic amplitude. While in controls brow motion accounted for about 3.3-9.3% of the lid saccades, it was responsible for more than 43.5-57.4% lid movements in the patients.

CONCLUSION

Fascial slings have a permanent restrictive effect on the elastic properties of the lids. Postoperative lagophthalmos is a natural consequence of any type of fascial sling. Downward saccadic amplitude is negatively correlated with the surgical effect with frontalis contraction.

Determination of the Amount of Ptosis Correction in Levator Resection Surgery for Pediatric Congenital Ptosis

BACKGROUND

It is difficult to determine the amount of eyelid lift in levator resection surgery for congenital ptosis, especially when the surgery is performed under general anesthesia. We aim to introduce an objective and steady method with which to adjust eyelid height, and to identify other factors to be considered during surgery.

METHODS

This is a retrospective, observational study of 110 eyes from 78 patients who underwent levator resection surgery for congenital ptosis. Postoperative eyelid height was observed chronologically. The amount of eyelid lift during surgery was compared with the real postoperative change of palpebral fissure width (PF). The factors influencing the postoperative changes in eyelid height were investigated to predict outcome.

RESULTS

Postoperative eyelid height stabilized 1 month after surgery. The real postoperative change in PF was slightly larger than the amount of intraoperative eyelid lift in cases with levator muscle function (LF) ≥ 7 mm, whereas it tended to be smaller in cases with LF < 5 mm. Statistically significant factors influencing the difference between the amount of intraoperative eyelid lift and the real postoperative change of eyelid height included preoperative PF, preoperative LF, and anesthesia-induced lagophthalmos.

CONCLUSION

The preoperative PF, preoperative LF, and anesthesia-induced lagophthalmos should be considered when determining the amount of ptosis correction to perform in levator resection surgery.

LEVEL OF EVIDENCE IV

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Spontaneous Blinking Kinematics in Patients Who Have Undergone Autogeneous Fascia Frontalis Suspension

PURPOSE

To measure spontaneous blink metrics and brow motion in patients with congenital ptosis operated with frontalis slings with autogenous fascia lata.

METHODS

An infrared three-dimensional video motion analyzer was employed to simultaneously measure brow motion and spontaneous blinks of 17 patients with congenital ptosis who underwent frontalis sling with autogenous fascia lata and a control group of equal number of healthy subjects. A customized software identified and quantified the amplitude and maximum velocity spontaneous blinks eyelid and brown motion during a 5-minute observation of a commercial movie. The corneal status of the patients with and without lagophthamos was evaluated with slit-lamp biomicroscopy with fluorescein staining.

RESULTS

Lagophthalmos was detected on 13 (76.5%) patients. Out of these 3 (23%) showed signs of inferior superficial keratopathy despite the presence of normal (upwards) Bell's phenomenon in all of them. Blink rate was significantly diminished in the patients. The distribution of interblink time was similar in both groups. The mean amplitude of the down-phase of the patients' blinks was only 38% of the controls. The main sequence slope of the patients' blinks was abnormally low. In controls brow motion was a minute and random event no related to blinks. In the patients, the mean brow amplitude was five times higher than in controls reaching 45% of the blink amplitude.

CONCLUSIONS

Spontaneous blink amplitude and velocity are severely impaired in patients with fascia lata autogenous slings. After surgery blinking amplitude is linearly related to the amplitude of brow motion.

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.

Refractive error characteristics in patients with congenital blepharoptosis before and after ptosis repair surgery

BACKGROUND

We examined the effect of surgical repair on the pattern of refractive errors in Korean patients with congenital blepharoptosis.

METHODS

We reviewed the clinical records of 54 patients with congenital blepharoptosis who attended our hospital from 2006 to 2012 and underwent a detailed refractive examination before and after ptosis repair surgery. Among them, 21 of the patients whose refractive data was available for both before and after the surgery were included in order to observe the effect of ptosis repair surgery on refractive error characteristics. The astigmatism groups were divided into three subgroups: with-the-rule (WTR), against-the-rule (ATR), and oblique astigmatism (OA). We also evaluated the severity of astigmatism.

RESULTS

Before surgery, the ptotic eyes had more severe astigmatism and a greater percentage of OA than the fellow eyes. The changes in astigmatism magnitude before and after surgery were not significant, but the proportion of subjects with OA increased significantly. In ptotic eyes, amblyopia was found in 14 eyes (20.9 %). 3 eyes (4.5 %) were from solely occlusive visual stimulus deprivation due to severe ptosis, and 11 eyes were from refractive errors. Among refractive errors, amblyogenic astigmatism made up to the largest proportion of patients (8 patients, 11.9 %).

CONCLUSIONS

Ptotic eyes had more severe astigmatism and more OA than fellow eyes. Amblyogenic astigmatism was more common in ptotic eyes. A change in astigmatism toward the OA axis was significantly detected after surgery, and that can be possible amblyogenic cause. Therefore, the correction of astigmatism before and after ptosis repair surgery is very important to prevent amblyopia.

Ptosis repair using preserved fascia lata with the modified direct tarsal fixation technique

Purpose

To evaluate the clinical outcome of frontalis sling operation using preserved fascia lata with modified direct tarsal fixation in congenital ptosis patients.

Methods

Forty-seven congenital ptosis patients (60 eyes) who underwent a frontalis sling operation using preserved fascia lata with modified direct tarsal fixation method between March 2001 and December 2008 with a mean follow-up time of 52 months (range, 26 to 122 months) were included in this study. The medical records were reviewed retrospectively.

Results

A retrospective chart review was conducted in patients who were diagnosed with congenital ptosis and underwent frontalis suspension surgery using preserved fascia lata with modified direct tarsal fixation from 2001 through 2008 at Dong-A University Hospital. The patients were 34 males and 14 females. The age of the patients ranged from 1 to 18 years with an average age of 4.51 years. At a mean follow-up of 60 months, good final results were achieved in 46 eyes (76.6%), fair in 8 eyes (13.3%), and poor in 6 eyes (10%). The poor results consisted of undercorrection of 1 eye and recurrence in 5 eyes. The accumulative survival rate was 87.2%, with all recurrences occurring within 12 months postoperatively.

Conclusions

Frontalis sling operation by preserved fascia lata with modified direct tarsal fixation appears to be an effective treatment for severe congenital ptosis, showing good long term results.

Effect of unilateral congenital ptosis on ocular higher order aberrations in children

To analyse the effect of congenital unilateral ptosis on the ocular higher order aberrations (HOA) and to compare these eyes with normal fellow eyes this study has been performed. In this observational comparative case series, 16 eyes of 16 patients less than 15 years old with congenital unilateral upper eyelid ptosis were included. Corrected distance visual acuity (CDVA), corneal topography, ocular HOA's with Zywave workstation was recorded. The amount of ptosis was measured from marginal reflex distance (MRD1). The ocular HOA's were compared between the ptosis and the normal fellow eyes after making necessary corrections to avoid errors due to enantiomeric midline symmetry. The mean age was 12.5±2.7years (range7-15years). The mean MRD1 was -0.9±1.8mm in the ptosis eyes. There was significant difference noted in the mean 6mm Zernicke coefficients Z3 (-3) (p=0.002), Z4 (-2) (p=0.034), Z4 (2) (p=0.008), Z5 (-5) (p=0.044), Z5 (1) (p=0.039), Z5 (3) (p=0.036), Z5 (5) (p=0.044) between the ptosis and the fellow eyes. The mean Z3-3 was -0.17±0.15 and 0.07±0.12 in the ptosis and the normal eyes respectively. There was a significant difference (p=0.023) in total RMS (root mean square) between the ptosis and the normal eyes. Total coma aberration correlated with CDVA (p=0.004) and MRD (p=0.030) in the ptosis eyes. There was no correlation (p=0.815) between the age (duration of ptosis) and total RMS. In conclusion, Eyes with congenital ptosis differed from their normal fellow eyes in the higher order aberrations. None of the HOA's which differed between the two groups affected the visual acuity in the ptosis eyes.

Total levator aponeurosis resection for primary congenital ptosis with very poor levator function

Aim:

This study was designed to evaluate the effectiveness of total levator aponeurosis resection in patients with very poor levator function secondary to primary congenital ptosis.

Design:

A retrospective, noncomparative single-institutional study was designed.

Participants:

Seven patients with very poor levator function secondary to primary congenital ptosis operated between May 2008 and May 2010 by one surgeon (AM).

Materials and Methods:

A retrospective study of seven patients with congenital ptosis evaluating eyelid elevation following total levator aponeurosis resection. End result is improvement of the eyelid elevation.

Conclusion:

Total levator aponeurosis resection is easy and effective tool in elevating the eyelid in patients with very poor levator function secondary to primary congenital ptosis.