Idiopathic intracranial hypertension in patients with Graves' ophthalmopathy

We report two cases of idiopathic intracranial hypertension in patients with Graves' ophthalmopathy. These patients, with known Graves' ophthalmopathy, presented with new onset optic disc edema and preserved visual function. Moderate enlargement of the extraocular muscles was observed in one case and moderate expansion of the orbital fat volume was observed in the second case. Lumbar puncture revealed an elevated opening pressure and normal cerebrospinal fluid composition in both patients. Also, no intracranial abnormalities were seen with neuroimaging studies. The findings in these patients suggest idiopathic intracranial hypertension as a second concurrent diagnosis, and should be considered as a possible etiology of optic disc edema in patients with Gravesþ ophthalmopathy and preserved visual function.     

A simple new method for the construction of a ptosis crutch

A technique by which a ptosis crutch can be fitted in minutes, using readily available and inexpensive materials and tools, is described. No specialist skills are needed and the device can be fitted to existing frames and lenses.     

How far we have come: A review of the evolution of posterior approach ptosis surgery

We revisit the evolution of posterior approach ptosis surgery. We address the early attempts at ptosis surgery, assess the more modern approach by de Blaskovics, followed by the division into “open sky” and “closed” techniques. The simultaneous developments occurring in America and Europe are described, along with refinement of surgical approaches such as conjunctival‐sparing posterior approach ptosis surgery.     

A new refined technique for myogenic ptosis correction with resection of myotarsal flap by conjunctival approach

The purpose is to present a new refined surgical technique for mild-to-severe acquired myogenic ptosis correction under local anaesthesia (LA) as day cases with resection of myotarsal (MT) flap and demonstrate the safety and efficacy of the technique. MT flap consists of 2 mm tarsal strip with attached levator complex – levator muscle, its aponeurosis, and Müller muscle.

This is a retrospective personal series of 400+ patients, who underwent surgical correction with MT flap resection of 8–24 mm under LA mostly as day cases.

No patient had any complication. Results were satisfactory as assessed on these criteria: (i) elevation of the lid at least above the visual axis; (ii) normal contours of the lid without distortion, with the eyelid conforming to the contours of the globe; (iii) static and dynamic symmetry of upper eyelids; (iv) formation of a normal and symmetrical lid fold; (v) healthy comfortable ocular surface and cornea; and (vi) patient and surgeon satisfaction with the aesthetic outcome.

Resection of the MT flap is a safe and effective, microsurgical technique of ptosis correction, yielding satisfactory results without complications, with ergonomic advantages of the inclusion of a tarsal strip. The versatility of the MT flap extends to its use for correction of upper lid retraction, and for formation of the posterior lamina of full thickness small to subtotal lower lid reconstructions.     

Levator aponeurosis surgery for the correction of acquired ptosis. Analysis of 113 procedures

Levator aponeurosis surgery was used to treat 113 upper eyelids with acquired ptosis. Ninety-five percent of the eyelids were corrected to within 1 mm of the desired result. The range of eyelift lift was 1 to 5.5 mm. Follow-up period for these patients was 6 months to 7 years. Local anesthesia is required for this technique since the lid height is determined by asking the patient to look in various fields of gaze. Levator function of at least 8 mm should be present if more than 1 mm of ptosis needs to be corrected.     

腱膜性上睑下垂的手术治疗

目的 探讨腱膜性上睑下垂的手术治疗方法及效果。方法 对10例（11眼）腱膜性上睑下垂患者施行提上睑肌腱膜折叠术,随访3-18月。平均8.5月。结果 所有病例上睑下垂得到矫正,收到良好的美容效果。结论 提上睑肌腱膜折叠术是矫治腱膜性上睑下垂的有效方法之一。     

Small incision external levator repair: technique and early results

PURPOSE: To describe a new surgical technique and early results of external levator repair performed through a small skin incision. METHODS: A chart review of consecutive patients undergoing small incision external levator repair was conducted. This modified external levator repair was performed through an 8-mm eyelid crease incision. Patients with unilateral or bilateral aponeurogenic blepharoptosis were candidates for the technique. Patients with excessive horizontal upper eyelid laxity and those requiring blepharoplasty in addition to blepharoptosis surgery did not undergo this technique. Patients who underwent previous upper eyelid surgery or concurrent brow surgery were excluded from the review. Preoperative measurements included upper eyelid margin reflex distance, levator function, and degree of dermatochalasis, as well as Goldmann visual field results. Outcome measures included incidence and type of intraoperative complications, postoperative upper eyelid position (including margin reflex distance, eyelid contour, and symmetry), incidence and type of postoperative complications, and revisions or additional necessary surgery. RESULTS: Twenty-eight eyelids of 17 patients met study inclusion criteria. Preoperative margin reflex distance +/- SD averaged 0.8 +/- 0.4 mm. Average length of follow-up was 28 +/- 5 weeks (range, 15 to 52 weeks). No significant intraoperative complications occurred. Postoperative margin reflex distance averaged 3.7 +/- 0.3 mm. Two eyelids were mildly undercorrected, and one demonstrated moderately peaked contour postoperatively. Satisfactory eyelid position and contour were achieved in 25 of 28 treated eyelids. No patient elected reoperation. CONCLUSIONS: Early results demonstrated that small incision levator repair is safe and generally effective. This minimally invasive external levator repair is useful for a carefully selected subset of patients with aponeurogenic blepharoptosis.     

Upper Lid Entropion Post Ptosis Correction: Is Tarsal Buckling the Cause?

Purpose: To report two cases of the rare complication of entropion following involutional ptosis surgery and its successful management.

Methods: Clinical findings and management of the patients are presented.

Results: Case 1: An 89-year-old female underwent aponeurosis advancement surgery for left involutional ptosis. Post-operatively she achieved good lid height, but had developed entropion of the upper lid which resulted in a persistent corneal epithelial defect. The patient underwent repeat surgery during which the aponeurosis was found to be inserted into the lower part of middle one third of tarsus with the tarsus itself being extremely thin. The aponeurosis was reinserted into upper third of tarsus, followed by greyline split with anterior lamellar repositioning. Post-operatively the patient achieved good lid height with correction of the entropion.Case 2: A 70-year-old male who had previously undergone bilateral brow lift and ptosis correction two years ago, was referred with right upper lid entropion. During surgery the aponeurosis was found to be inserted into the lower part of middle one third of tarsus, with a very thin tarsus. This patient was also managed by reinserting aponeurosis into upper third of tarsus with grey line split and anterior lamellar repositioning following which he achieved good lid height and correction of the entropion.

Comment:Entropion has rarely been reported as a complication of ptosis surgery. This case series highlights the importance of taking special care when advancing the aponeurosis, in cases where the tarsus is thin, as it may result in vertical buckling of the tarsus.     

Inferior tarsal muscle-conjunctivectomy for reverse ptosis repair: A novel technique

We describe a new technique for treatment of reverse ptosis in a patient with Horner Syndrome by means of excision of conjunctiva and inferior tarsal muscle. Surgery with eversion of inferior ptotic eyelid, placement of the Putterman ptosis clamp on the conjunctiva under inferior tarsus, suturing under incarcerated tissue and resection of 6mm of conjunctiva and inferior tarsal muscle was done under local anaesthesia in a short operating time with good cosmetic results without eyelid malposition or skin scar.     

The Prevalence of Ptosis and Its Association with Amblyopia and Strabismus in 7-Year-Old Schoolchildren in Iran

Abstract

Purpose: To determine the prevalence of ptosis (congenital/acquired) in Iranian children aged 7 years and its relationship with amblyopia and strabismus.

Methods: Eight Iranian cities were selected for this cross-sectional study using multistage randomized cluster sampling. A number of primary schools were randomly selected in each city. All grade 1 students in each selected primary school underwent optometric examinations including the measurement of uncorrected and corrected visual acuity, cover test, and cycloplegic and non-cycloplegic refraction.

Results: Of 4614 selected students, 4106 students participated in the study (response rate?=?89%). The prevalence of ptosis (congenital/acquired) was 1.41% (95% CI 1–1.83); 0.49% (95% CI 0.26–0.72) and 0.93% (95% CI 0.59–1.26) had unilateral and bilateral ptosis, respectively. The prevalence of ptosis had no significant correlation with sex (p?=?0.810, OR?=?1.07, 95% CI 0.59–1.97). The prevalence of amblyopia was 48.28% and 0.89% in students with and without ptosis, respectively. The prevalence of tropia was significantly higher in cases with bilateral ptosis (p?<?0.001). The mean cylinder error was 1.63?±?1.72 and 0.44?±?0.60 in ptotic and non-ptotic eyes, respectively (p?<?0.001). With-the-rule (WTR) astigmatism was significantly more prevalent in students with ptosis.

Conclusion: We report the prevalence of ptosis (congenital/acquired) in children in Iran and the Middle East region for the first time. Amblyopia was considerably more prevalent in ptotic patients. We found a significant correlation between ptosis and tropia. Astigmatism, especially WTR stigmatism, was more prevalent in children with ptosis.     

Levator surgery and histology in congenital and senile ptosis

Analysis of the levator operations between 1978 and 1983 in the University Eye Hospital Kiel demonstrates that transconjunctival levator operations are more and more abandoned in favour of the transcutaneous approach. The advantages and disadvantages of both methods are discussed.

The transcutaneous approach offers a better view together with a more individually adapted dosage and modification of the technique. Histology confirms that in congenital ptosis the degenerations and atrophy are present mainly in the muscular part of the levator while in acquired ptosis the pathology can be found in the aponeurosis. Here the therapy should be aimed at this latter part of the muscle.

Proper estimation of the dosage of resection is a must for the avoidance of complications. If possible the Whitnall ligament should be left intact.     

Scleral contact lenses for the management of complicated ptosis

Purpose: To present the management of three patients suffering from ptosis of various etiologies, with scleral contact lenses.

Material and methods: Three patients (five eyes) with ptosis resulting from levator dehiscence due to long-term rigid gas permeable contact lens wear for keratoconus, phthisis bulbi, and myopathy due to Kearns–Sayre syndrome were identified during a 2-year period. They were fitted with scleral contact lenses in order to provide cosmesis by lifting the upper eyelid with the bulk of the lens, and simultaneously provide vision correction where applicable.

Results: The scleral contact lenses provided comfortable wear, significantly improved cosmesis as both palpebral aperture and marginal reflex distance were increased, and visual acuity was also subjectively and objectively improved. Two of the patients opted for the scleral contact lenses, whereas the parents of the third patient, a 10-year-old girl with Kearns–Sayre syndrome, chose to undergo ptosis surgery due to handling issues of the scleral contact lenses.

Conclusion: Scleral contact lenses can be a useful addition to the treatment option for patients with complicated ptosis.     

Comparing the outcomes of severe versus mild/moderate ptosis using closed posterior levator advancement

Traditionally, posterior eyelid surgical approaches such as Müller’s muscle-conjunctival resection (MMCR) have been utilised with great success for mild cases of ptosis, with external levator approaches having been used for more severe cases of ptosis. We present a new technique which we label closed posterior levator advancement (CPLA) for the correction of all grades of ptosis. This article is a retrospective cohort study reviewing patients with mild, moderate, and severe ptosis over a 6-year period, treated by a single surgeon using CPLA. Minimum follow-up was 3 months. Patients with good levator function (levator palpebrae superioris (LPS) function >10 mm) without concomitant procedures were subdivided based on margin-to-reflex-distance-1 (MRD1) into mild-to-moderate ptosis (MRD1 > 1.5 mm) and severe ptosis (MRD1 ≤ 1.5 mm) cohorts. The outcome measures were preoperative and postoperative MRD1, lid contour, intereye symmetry, complications, and revision rates. 393 eyes of 313 patients were identified. 91 eyes in the mild-to-moderate cohort had a preoperative MRD1 of 2.38 mm, and 302 eyes in the severe cohort had a preoperative MRD1 of 0.27 mm. Postoperatively, MRD1 was 3.86 mm and 3.49 mm, respectively. There were no significant complications in both cohorts, and revision rates were 3.3% (3 of 91 eyes) in the mild-to-moderate and 2% (6 of 302 eyes) in the severe cohorts. Upper-eyelid contour was satisfactory in 98.2% of eyes, and 97.5% intereye symmetry within 1 mm was observed. Our results show an effective correction of all ptosis grades with satisfactory cosmetic outcomes and low complication and revision rates.     

The psychological well-being and appearance concerns of patients presenting with ptosis

Purpose

Ptosis affects both the function and appearance of the eyes and face, because of drooping of the eyelids. Previous research has focused on functional impairment; however, similar appearance altering eye conditions have been demonstrated to have major impacts on psychosocial functioning.

Methods

This study examines the psychological well-being and appearance concerns of patients presenting with ptosis recruited from Bristol Eye Hospital using validated questionnaires focusing on demographics and psychosocial factors before surgery.

Results

Patients reported higher levels of anxiety, depression, and appearance concern than population norms, with scores comparable to previous research examining the impact of other disfiguring eye conditions. Gender differences were observed, with almost half of females experiencing significant psychosocial issues related to appearance concern about their ptosis compared with 20% of males. Linear regressions revealed that the main predictor of poor adjustment to the appearance of ptosis was the level of concern an individual had regarding the negative perceptions of other people. These results implicate psychosocial factors and demographics as predictors of the development of appearance-related distress and compromised psychological well-being for patients with ptosis who are currently seeking surgery.

Conclusions

This study provides clinicians with a greater understanding of the concerns of affected patients, and treatment motivations. The findings may also inform the development of patient reported outcome measures and support for patients, which targets the psychosocial impact of the condition.     

扇形额肌瓣悬吊术矫正重度上睑下垂临床分析

目的探讨重度上睑下垂的最佳手术方法。方法采用扇形额肌瓣悬吊术矫正重度上睑下垂126例（148眼）。术后随访3月～6年，观察其效果：结果我院采用扇形额肌瓣悬吊术矫正重度上睑下垂的148眼中，除3眼下垂复发外，均取得良好效果。结论扇形额肌瓣悬吊术矫正重度上睑下垂，保留额肌的神经支配和血液供应，代替上睑提肌的开睑作用，是目前符合生理功能的手术方法。     

Congenital ptosis

Congenital blepharoptosis presents within the first year of life either in isolation or as a part of many different ocular or systemic disorders. Surgical repair is challenging, and recurrence necessitating more than one operation is not uncommon. Not all patients with congenital ptosis require surgery, but children with amblyopia due to astigmatic anisometropia or deprivation may benefit from early surgical correction. A variety of surgical procedures to correct congenital ptosis have been described. The choice of procedure depends on a number of patient-specific factors, such as degree of ptosis and levator function, as well as surgeon preference and resource availability. We review the genetics, associated syndromes, and surgical treatments of congenital ptosis.     

Pembrolizumab and epacadostat induced fatal myocarditis and myositis presenting as a case of ptosis and ophthalmoplegia

We report the first case of fatal myocarditis presenting as bilateral ptosis in a patient on combination therapy with pembrolizumab and epacadostat. An 83 year-old man with stage III high-grade urothelial carcinoma presented with acute onset droopy eyelids one month after starting pembrolizumab and epacadostat. Exam showed myogenic ptosis and ophthalmoplegia. He was later found to have acute myocarditis with complete heart block and subsequently passed away. Pembrolizumab in combination with epacadostat can induce a potentially fatal myocarditis. Although immune mediated myocarditis is a rare established side effect, more reported fatalities are needed in the literature to highlight the urgency for standardized cardiac monitoring of even asymptomatic patients to prevent fatal outcomes, as well as a consensus on treatment protocols. Cancer immunotherapy complications are not well known to ophthalmologists. This case is unique in that the presenting sign was ptosis, which prompted the patient to call his ophthalmologist first.     

先天性上睑下垂发病机制与手术设计的研究

目的：探讨先天性上睑下垂的发病机制，为手术方法的设计提供依据。方法：对73例（103眼）先天性上睑下垂进行了上睑提肌肌力，肌电图，肌弹性的测量及解剖学，组织学方面的观察。结果：肌电图显示该肌收缩强度正常平均值为500uV/D，部分肌力较差的患者（18％）肌收缩强度达260－350uV/D接近正常平均值，少数骨力在3－5mm的患者（9．99％）肌收缩强度达到正常平均值。术中观察85％的患者上睑提肌弹性良好，肌伸民可达15－20mm。组织学观察发现17％的患者上睑提肌为正常组织，结论：先天性上睑下垂的发生原因除肌发育不良外，上睑提肌内，外角过度紧张也是其重要因素，并根据病因制定了合理有效的手术 方式。     

Acquired Horner Syndrome in a Mother and Daughter

A 41-year old right handed white woman woke up with a dull, pressure -like headache in the right orbit. While she was putting on her makeup, she noticed drooping of her right upper eye lid. Her headache did not interfere with her activities of daily living. She thought she was experiencing a “sinus headache”. She does not recall when her headache went away but denies taking any medications for it. She denied any other associated symptoms with this episode.

One week following this episode, the patient experienced the “worst headache of her life” and went to the hospital for further evaluation. Her ophthalmologic and neurologic exams were normal except for a right Horner syndrome.

The patient's evaluation included an MRI/MRA of the brain, a four vessel angiogram, a CT of the chest, and an MRI of the cervical and thoracic spine, all of which were normal. The mother of the patient had also developed a Horner syndrome at a similar age. Familial congenital Horner syndrome has been described in the literature. To our knowledge, this represents the first case report of familial acquired Horner syndrome.     

Ptosis prop gas permeable scleral lens fitting for a patient with ocular myopathy

This case report outlines the contact lens management of a patient with ocular myopathy who subsequently developed marked bilateral ptosis. The patient was successfully fitted with a pair of ptosis prop gas permeable scleral lenses.