Blepharoptosis Repair through the Small Orbital Septum Incision and Minimal Dissection Technique in Patients with Coexisting Dermatochalasis

Purpose

To describe a modified surgical technique for blepharoptosis repair through a small orbital septum incision and minimal dissection, along with the results obtained in patients with coexisting dermatochalasis.

Methods

A retrospective chart review included 33 patients (52 eyelids) with blepharoptosis coexisting with dermatochalasis, surgically corrected through a small orbital septum incision and minimal dissection after redundant upper lid skin excision, by placing a single fixation suture between the levator aponeurosis and the tarsal plate. Outcome measures included the pre- and postoperative marginal reflex distances (MRD1), eyelid contour, post-operative complications, and need for reoperation.

Results

The pre- and postoperative MRD1 averaged 1.1 ± 0.8 mm and 2.8 ± 1.1 mm, respectively. Of the 33 patients, 9 patients (9 eyelids) underwent surgery on one eyelid for unilateral blepharoptosis and dermatochalasis (Group I), 5 patients (5 eyelids) underwent a simple skin excision blepharoplasty of the contralateral eyelid (Group II), and 19 patients (38 eyelids) underwent bilateral blepharoptosis and dermatochalasis repair (Group III). Of the 14 eyelids that underwent unilateral ptosis repair (Groups I and II), 12 eyelids (85.7%) showed less than a 1-mm difference from the contralateral eyelid. Of the 38 eyelids that underwent bilateral ptosis repair (Group III), 27 eyelids (71.1%), 5 eyelids (13.1%), and 6 eyelids (15.8%) had excellent, good, and poor outcomes, respectively. Overall, 44 eyelids (84.6%) out of a total of 52 eyelids had successful outcomes; the remaining 8 eyelids demonstrated unsatisfactory eyelid contour was corrected by an additional surgery.

Conclusions

Blepharoptosis repair through a small orbital septum incision and minimal dissection can be considered an efficient technique in patients with ptosis and dermatochalasis.     

Effect of unilateral blepharoptosis repair on contralateral eyelid position

PURPOSE: This study evaluates the effect of unilateral blepharoptosis repair on contralateral eyelid position and assesses the relation between preoperative eyelid height interdependence, consistent with Hering law, and surgical outcome. METHODS: The medical records of 54 patients (21 men, 33 women; mean age, 65 years) who underwent external levator advancement for unilateral aponeurotic blepharoptosis were reviewed for preoperative and postoperative margin reflex distance (MRD) of the nonoperated eye. To assess the relation between preoperative Hering dependence (mechanical elevation of the ptotic eyelid causing a decrease in contralateral eyelid height) and postoperative eyelid position, the change in MRD of the nonoperated eye was compared between subjects who on preoperative evaluation did (n=18) and did not (n=36) demonstrate eyelid height interdependence, using the 2-sample t test. RESULTS: After unilateral blepharoptosis repair, the mean (+/- SD) change in contralateral MRD was -0.2 +/- 0.8 mm. There was no significant difference in contralateral MRD change in subjects with and without preoperative Hering dependence (-0.3 +/- 0.8 mm versus -0.2 +/- 0.9 mm, respectively, p=0.78). Seventeen percent (9 of 54) of patients had a contralateral MRD decrease of more than 1 mm. Three patients (5.6%) required contralateral blepharoptosis repair within 1 year of initial surgery. CONCLUSIONS: After levator advancement for unilateral blepharoptosis, roughly 17% of patients will have a decrease in contralateral eyelid height of more than 1 mm, with 5% of patients requiring surgical repair during the first postoperative year. The degree of change in contralateral eyelid height cannot be reliably predicted by preoperative assessment of Hering dependence.     

Comparison of two- and three-point sutures for advancing the levator aponeurosis in Asian eyelids

Purpose

To compare the functional and cosmetic outcomes of two- and three-point sutures for advancing the levator aponeurosis in blepharoptosis surgery on Asians.

Patients and methods

This retrospective study examined 60 Asian patients with blepharoptosis who had undergone advancement of the levator aponeurosis: 34 patients (46 eyelids) had ptosis correction using the two-point suture technique and 26 patients (41 eyelids) had ptosis correction using the three-point suture technique. The postoperative marginal reflex distance (MRD1), lid height difference, and eyelid contour were evaluated.

Results

Twenty-seven (79.4%) of the 34 patients in the two-point group and 19 (73.1%) of 26 patients in the three-point group had a postoperative MRD1 of 2–4 mm, lids within 0.5 mm of each other, and a satisfactory eyelid contour; this difference was not significant. The rate of reoperation did not differ significantly between the two groups.

Conclusion

Two- and three-point sutures for advancing the levator aponeurosis were equally effective for correcting blepharoptosis in Asians.     

Ultrasound biomicroscopy of the levator aponeurosis in congenital and aponeurotic blepharoptosis

PURPOSE: To evaluate and measure the thickness of the levator aponeurosis by ultrasound biomicroscopy in congenital dysmyogenic and aponeurotic blepharoptosis. METHODS: Forty-four upper eyelids of 22 patients who had unilateral blepharoptosis were evaluated by ultrasound biomicroscopy. The patients ranged in age from 13 to 69 years (mean, 35.4 +/- 20.2 years). Fourteen patients were male and 8 patients were female. Seven patients had congenital dysmyogenic blepharoptosis and 15 patients had aponeurotic blepharoptosis. Imaging was performed with a 50-MHz transducer. The thickness of the levator aponeurosis was measured centrally at the upper border of the tarsus. RESULTS: The levator aponeurosis was imaged in all eyelids except for one eyelid with aponeurotic blepharoptosis. The mean thickness of the levator aponeurosis was 0.39 +/- 0.10 mm in the ptotic eyelid and 0.42 +/- 0.09 mm in the control eyelid of the patients with congenital dysmyogenic blepharoptosis (p = 0.043). The mean thickness of the levator aponeurosis was 0.26 +/- 0.05 mm in the ptotic eyelid and 0.36 +/- 0.04 mm in the control eyelid of the patients with aponeurotic blepharoptosis (p = 0.001). The thickness of the levator aponeurosis was correlated with the palpebral fissure height (p = 0.013, r = 0.644) in aponeurotic blepharoptosis. The thickness of the levator aponeurosis was correlated with the levator function (p = 0.033, r = 0.795) in congenital dysmyogenic blepharoptosis. CONCLUSIONS: The thickness of the levator aponeurosis can be measured with ultrasound biomicroscopy. The most common pathology in aponeurotic blepharoptosis is thinned-out aponeurosis. The levator aponeurosis of the ptotic eyelid is thinner than the normal eyelid in congenital ptosis.     

Surgical method and results of levator aponeurosis transposition for Graves' eyelid retraction

Predictability of final eyelid height and contour following surgical correction of eyelid retraction remains problematic. We describe our surgical method and results with the distal levator aponeurosis transposition procedure for eyelid retraction. The procedure consists of disinserting the distal levator aponeurosis from the tarsal plate and excising Muller's muscle. The lateral three-fifths of the distal aponeurosis is fashioned into a flap that is disinserted laterally, rotated inferiorly 90 degrees, and attached to the tarsal plate. Distal levator transposition is useful in the management of dysthyroid retraction and in the reduction of the margin reflex distance (MRD) asymmetry between upper eyelids. However, it shares with other eyelid lowering procedures, the disadvantage of poor predictability of final MRD.     

A modified posterior approach for upper eyelid retraction

PURPOSE: To describe and review a graded technique for lowering the upper eyelid from a posterior approach, recessing or resecting Müller muscle and levator aponeurosis but leaving a central pillar of Müller muscle intact, occasionally including a temporal tarsorrhaphy or superior tarsal strip where needed, and performing tissue dissection with a hot-wire cautery instrument. METHODS: A 10-year retrospective chart review was performed. Where follow-up was less than 6 months, telephone interviews were conducted to assess patient satisfaction with the procedure. Statistical analysis was performed using an unpaired t test. RESULTS: Ninety-nine patients (161 eyelids, 62 bilateral and 37 unilateral) with a mean age of 47 years (range, 21-82 years) were studied. The mean follow-up period was 61 months. The mean preoperative and postoperative margin reflex distances (MRD1) were 7.3 mm (range, 4.5-10 mm) and 4.3 mm (range, 2-7 mm), respectively. Eighty-nine percent (144/161 eyelids) achieved the target result of an MRD1 of 4 +/- 1 mm after one procedure. Fifteen eyelids (9% of operated eyelids) required a second procedure, and in this group, 2 (13% of the reoperated eyelids) underwent a third procedure. Although bilateral cases were more likely to achieve symmetry (p = 0.0071), 90% of either unilateral or bilateral cases achieved a postoperative MRD1 of 4 +/- 1 mm. Both mild (MRD1 of 5-7 mm) and severe (MRD1 > 7 mm) cases of eyelid retraction achieved similar operative outcomes. In the first 6 months after surgery, complications included undercorrection (8 eyelids), overcorrection (2 eyelids), and pyogenic granuloma (2 eyelids). None had a flattened upper eyelid contour. Late recurrence of retraction was seen in 9 eyelids. Mean operative time was 16 minutes per eyelid. CONCLUSIONS: This technique of lowering the retracted upper eyelid is effective even in severe cases of eyelid retraction. Minimal complications were encountered, and upper eyelid contours were well preserved. The use of hot-wire cautery dissection proved useful in shortening operative time.     

Unilateral frontalis sling for the surgical correction of unilateral poor-function ptosis

PURPOSE: To evaluate the functional and cosmetic results after frontalis sling repair for unilateral ptosis associated with either poor levator function or synkinesis. METHODS: Preoperative and postoperative photographs and records of 127 patients who underwent unilateral frontalis sling ptosis repair were retrospectively reviewed. An eyelid crease incision was used in all cases, with suturing of the sling material directly to tarsus. RESULTS: Preoperative diagnosis for all patients was either unilateral poor-function blepharoptosis or ptosis associated with levator synkinesis. Underlying causes included 75 congenital, 13 posttraumatic, 11 congenital "jaw-winking," 10 cranial nerve III palsies, 9 myasthenia gravis, 5 chronic progressive external ophthalmoplegia, and 4 congenital "double-elevator" palsies. There was a mean follow-up of 11.6 months. Twenty-eight eyelids required reoperation: 11 for undercorrection, 6 for overcorrection with keratopathy, 2 for upper eyelid crease revision, 7 for correction of poor contour, 1 for a broken sling, and 1 for removal of an infected exposed polytetraflouroethylene sling. Lagophthalmos of greater than 2 mm was noted in 18 patients, 5 of whom had persistent keratopathy requiring reoperation. No other complications were reported, except for 1 suture granuloma. Good to excellent final postoperative eyelid height was achieved in 121 patients (95%) after all surgeries and with conscious recruitment of the frontalis muscle. A large majority of patients and/or parents expressed satisfaction with the final cosmetic result and were not bothered by any asymmetric lagophthalmos in downgaze or lack of a synchronous blink. However, 19 of 25 amblyopic patients were less satisfied with passive eyelid height as they failed to recruit the ipsilateral frontalis muscle to activate the sling during binocular viewing. In 17 of these 19 patients, good to excellent eyelid height could be achieved with conscious active brow elevation. CONCLUSIONS: Unilateral sling provides good to excellent functional and cosmetic results in unilateral poor-function ptosis. However, patients with amblyopia usually require conscious effort to activate the frontalis muscle to achieve satisfactory eyelid height.     

Modified tarsal resection operation for congenital ptosis with fair levator function

PURPOSE: There are many options for surgical repair of congenital ptosis with fair levator function. The authors review their 10-year experience with an en bloc resection of tarsus, Müller muscle, and conjunctiva in conjunction with graded levator aponeurosis advancement (a variation of the tarsectomy operation). METHODS: This is a retrospective case series that reviews all cases of ptosis repair performed at West Virginia University from 1994 to 2004 using the "modified tarsal resection method." Thirty patients with congenital ptosis and fair levator function were identified. Follow-up ranged from 6 weeks to 8 years. Charts were reviewed for type of ptosis, pre- and postoperative upper eyelid margin to reflex distance, degree of levator function, amount of operative tarsus and Müller muscle resection, postoperative eyelid symmetry, and postoperative complications. RESULTS: In patients with congenital ptosis and fair levator function, the average preoperative upper eyelid margin to reflex distance was 0.0 mm and the average postoperative upper eyelid margin to reflex distance was 2.8 mm. Twenty-five of 30 (83%) patients were deemed to have a "good" surgical outcome. The amount of tarsus-Müller muscle resection reliably predicts the amount of eyelid elevation. The only complications to date have been transient lagophthalmos with exposure keratitis. CONCLUSIONS: In the authors' hands, an en bloc resection of tarsus, Müller muscle, and conjunctiva combined with levator aponeurosis advancement reliably produces excellent results in the treatment of fair levator function congenital ptosis, superior to their previous experience with isolated maximal levator aponeurosis advancement.     

The effect of upper eyelid blepharoplasty on eyelid and brow position

This article evaluates the effect of upper eyelid blepharoplasty on eyelid margin position and brow height. This study is a retrospective analysis of patients who underwent upper eyelid blepharoplasty without concurrent blepharoptosis repair or brow surgery. The medical records of the participants were retrospectively reviewed and an established image analysis software was used to quantify the upper margin reflex distance (MRD1) as well as brow height using high quality standardized clinical photographs. A total of 19 patients (38 eyelids and brows) met the inclusion criteria. The mean preoperative MRD1 was 2.8 mm, and the mean post-operative MRD1 was 3.5 mm, revealing an increase of MRD1 from upper blepharoplasty alone of 0.7 mm (p = 0.0001). The mean preoperative brow position was 17.5 mm above the pupil, and the mean post-operative position was 17.4 mm, for an average change of position of -0.2 mm (p = 0.39) following upper eyelid blepharoplasty. Upper eyelid blepharoplasty without ptosis surgery results in a statistically significant increase in MRD1. Brow position does not demonstrate a statistically significant change in patients who undergo upper eyelid blepharoplasty for simple dermatochalasis.     

Canthus-sparing ectropion repair

PURPOSE: To describe a novel surgical technique for lower eyelid ectropion repair that avoids canthotomy and cantholysis and can be used in combination with external levator repair and/or in combination with blepharoplasty. METHODS: A retrospective analysis of lower eyelid procedures with the use of the canthus-sparing technique between January 1, 1998, and December 31, 1999, was performed. The canthus-sparing approach was used in 198 eyelid procedures for the correction of lower eyelid ectropion. Seventy-four (37.4%) procedures involved the correction of lower eyelid ectropion alone and 25 (12.6%) procedures involved the correction of lower eyelid ectropion during upper eyelid small-incision external levator repair. In these cases, an incision was made lateral to the lateral canthus and a periosteal flap was created at the lateral orbital rim. The inferior crus of the lateral canthal tendon was then attached to this full-thickness elevated periosteum. Twenty (10.1%) procedures involved the correction of ectropion during upper blepharoplasty and 79 (39.9%) procedures involved the correction of ectropion during combined upper eyelid ptosis repair and blepharoplasty. In these cases, the inferior crus of the lateral canthal tendon was attached to a periosteal flap created through the lateral portion of the blepharoplasty incision. RESULTS: The mean age of patients undergoing ectropion repair was 74.3+/-9.3 years (range, 42-93 years). The average duration of symptoms (most commonly tearing and/or ocular irritation) was 20+/-14 months (range, 3-84 months). Recurrences of lower eyelid ectropion or symptoms occurred in 4 (2%) eyelids. The average follow-up interval was 54+/-65 days (range, 3-330 days). CONCLUSIONS: The canthus-sparing approach to ectropion repair promotes a secure adhesion to the lateral orbital wall with minimal violation of normal anatomic structures and relations. It is time-efficient and reduces postoperative morbidity.     

Correlation of the vision-related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery.

OBJECTIVE: To assess the effect of blepharoptosis on patients' visual function and health-related quality of life and to determine what measures are associated with postsurgical change in functional status. DESIGN: Prospective, observational case series. PARTICIPANTS: One hundred patients with unilateral or bilateral blepharoptosis. INTERVENTION/MAIN OUTCOME MEASURES: Preoperative and postoperative upper eyelid position (i.e., margin reflex distance [MRD]) and superior visual field (SVF) height, as well as subjective visual function and health-related quality-of-life functional status before and after ptosis surgery. RESULTS: There was a mean 30-point increase in functional index score after ptosis repair (P < 0.001). Lower (more ptotic) preoperative upper eyelid position and SVF (combined eye) were associated with greater change in functional index after surgery (r = -0.290, P = 0.007 and r = -0.39, P = 0.003, respectively). Preoperative visual field testing with manual lid elevation was not significantly correlated to the postoperative change in functional index (P > 0.100). The strongest correlation of postoperative functional index change was with the preoperative functional status (r = -0.79, P < 0.001). CONCLUSIONS: Patients' functional status is reduced by blepharoptosis, and surgical repair results in measurable increase in health-related quality of life. Patients' self-reported preoperative functional impairment is most strongly associated with the degree of postsurgical functional improvement.     

Lower eyelid reverse ptosis repair

PURPOSE: To report the results of the surgical repair of lower eyelid reverse ptosis. METHODS: Retrospective case series. Eight patients ranging in age from 31 to 77 years underwent surgical repair of lower eyelid reverse ptosis. The pupillary axis of the affected eye(s) in each patient was obscured in downgaze, interfering with reading. The lower eyelid reverse ptosis resulted from involutional changes in 3 patients, previous orbital decompression in 3 patients, multiple prior retinal and extraocular muscle operations in 1 patient, and previous orbital floor fracture and repair in 1 patient. Transcutaneous advancement of the lower eyelid retractors was performed in 12 eyelids of the 8 patients. RESULTS: The mean preoperative vertical eyelid fissure was 6.2 mm (median, 6 mm; range, 3-9 mm), increasing after surgery to a mean of 7.7 mm (median, 8 mm; range, 5-11 mm). The mean preoperative distance between the central light reflex and the lower eyelid margin was 1.7 mm (median, 1.25 mm; range, 1-4 mm); this distance increased to a mean of 3.3 mm (median, 3.25 mm; range, 2.5-4.5 mm) after surgery. Symptoms improved in all patients, and there were no perioperative complications. Follow-up intervals ranged from 2 months to 24 months (mean, 9 months; median, 13 months). CONCLUSIONS: Analogous to upper eyelid ptosis repair by advancement of the levator aponeurosis, lower eyelid reverse ptosis may be corrected effectively and safely by advancing the lower eyelid retractors.     

同期手术矫正上睑内翻倒睫合并老年性上睑下垂

目的：评价同期手术治疗上睑内翻合并老年性上睑下垂的手术效果。
　　方法：将2010-06/2013-06明确诊断为上睑内翻合并腱膜性上睑下垂的患者30例60眼同期行上睑内翻倒睫矫正合并提上睑肌缩短合并前徙术,观察手术后效果。
　　结果：术中全部矫正良好,分别于1 wk;1,6 mo对参选患者内翻及倒睫矫正情况及上睑遮盖上方角膜缘程度进行观察。上睑内翻倒睫得到完全矫正。上睑遮盖上方角膜缘垂直距离术后1wk 为1.68±0.71mm,1mo 为1.71±0.69mm,6mo为1.70±0.65mm,均较术前相比差异有统计学意义(P<0.05)。术后无暴露性角膜炎,无过矫发生。
　　结论：多数患有上睑内翻倒睫的老年人同时合并有老年性上睑下垂,眼科医生应该重视上述两种病变的合并存在,并同时矫正。同期行上睑内翻矫正合并提上睑肌缩短的方法治疗上睑内翻倒睫合并老年性上睑下垂,可取得满意疗效。     

Advances in the diagnosis and treatment of ptosis

PURPOSE OF REVIEW: The surgical correction of blepharoptosis, both congenital and acquired, has been intensively examined and reported on for many years. This paper reviews recent publications on basic science, evaluation, technique modifications, and innovative materials in the care of ptosis patients. RECENT FINDINGS: The frontalis suspension technique is a commonly performed surgical correction of congenital blepharoptosis, used widely in the repair of ptosis with poor levator function. The repair typically includes using either tissue such as autologous or banked fascia lata or permanent suture material. The procedure involves connecting the motor unit (frontalis muscle) and the upper eyelid. Authors have recently reintroduced the technique of a dynamic frontalis muscle flap tunneled into the eyelid that directly attaches to the tarsal plate.Patients presenting with symptomatic blepharoptosis due to disinsertion or thinning of the levator aponeurosis require surgical repair. Multiple groups have tended toward a minimally invasive approach directed specifically at the levator aponeurotic defect. Proposed advantages of a small eyelid incision (8-13 mm) include less local anesthetic and tissue distortion, less ecchymosis and edema, decreased operative times, a shortened recovery period, and improved surgical results. SUMMARY: Surgical correction of congenital blepharoptosis may be performed with autologous fascia lata, cadaveric allograft, or permanent suture material. The use of a frontalis muscle advancement flap is elegantly designed; however, its role in clinical practice remains to be defined. Advancement of the levator aponeurosis for senile blepharoptosis may be preformed via a minimally invasive small incision approach. Patients benefit with decreased operative time, edema, ecchymosis, and recovery times.     

Early Frontalis Flap Surgery as First Option to Correct Congenital Ptosis with Poor Levator Function

Abstract

In congenital blepharoptosis the upper eyelid cannot be lifted normally because of congenital impairment in the levator function. The descended eyelid margin partially or completely obstructs of the visual axis with the consequent risk of amblyopia. Frontalis suspension is the surgery of choice for ptosis with poor levator function creating a linkage between the frontalis muscle and the tarsus; the frontalis muscle is used to elevate the eyelid. Direct transplantation of frontalis muscle to the upper eyelid has been widely described. We report our experience using frontalis flap in congenital ptosis with poor levator function in children.

Methods: Retrospective study of 30 eyes with severe congenital ptosis and poor levator function treated by means of direct frontalis flap. Mean age 2 years. Eyelid measurements were taken at baseline, 1, 3, 12 months postoperatively and last visit. Mean ptosis degree was 5?mm (3--8?mm) and levator function 2?mm (1--5?mm). The presence of complications, flap function and palpebral contour were evaluated. Mean follow up time was 27 months. At last visit, ptosis degree ranged from 0 to 3?mm.

Discussion: Direct advancement of the frontalis muscle to treat severe eyelid ptosis is effective and stable in the long term avoiding the use of a linking structure, therefore the risk of foreign-body reaction, absorption, granuloma and late exposure, as well as the need for a second visible incision in the forehead. Patients learn how to control the lid height by means of the frontalis muscle achieving more symmetry.     

Ptosis secondary to anterior segment surgery and its repair in a two-year follow-up study

OBJECTIVE: Aponeurotic blepharoptosis is a postoperative complication of anterior segment surgery with a reported incidence of 1-2% and a variable aetiology. In this 2-year follow-up study, we investigated the incidence of this postoperative complication in our experience of anterior segment surgery and propose a modified technique of aponeurosis advancement for its repair. METHODS: 200 consecutive patients undergoing anterior segment surgery in our eye clinic were enrolled in the study. Patients who developed any other operative or postoperative complication were excluded from the study. In all patients, the following upper lid parameters were calculated to determine whether postoperative blepharoptosis had occurred: margin-reflex distance, upper eyelid crease, use of frontalis muscle and levator function. A questionnaire was submitted to all blepharoptosis patients investigating mainly their subjective judgement of the impact of blepharoptosis on their quality of life and if they had been informed accurately about the incidence of this postoperative complication. RESULTS: 163 patients were included in our study. 11 had postoperative blepharoptosis (6.7%). 9 patients wanted ptosis repair and were operated on with our modified technique. None of the 11 ptosis patients had been informed about the possible occurrence of the blepharoptosis as postoperative complication. Our modified technique shows good, long-lasting results. CONCLUSIONS: Postoperative blepharoptosis is a well-known postoperative complication of anterior segment surgery. It can be successfully treated surgically by aponeurosis advancement. It is our opinion that all patients should be informed of the possibility of postoperative blepharoptosis when consenting for anterior segment surgery.     

Surgical correction of blepharoptosis in patients with myasthenia gravis

PURPOSE: To describe the results of surgical correction of blepharoptosis in a series of patients with myasthenia gravis (MG). METHODS: In this retrospective case series, we reviewed the medical records of all patients with MG who did not respond to medical therapy and underwent surgical correction for blepharoptosis at the Mayo Clinic between 1985 and 1999. The primary outcome measure was change in interpalpebral eyelid fissure height. RESULTS: Sixteen blepharoptosis procedures were performed on 10 patients with MG. Eight of the 10 patients had ocular MG. Two of the 10 patients had systemic MG. Of the 16 procedures performed, 9 were external levator advancements (ELA), six were frontalis slings, and one was a tarsomyectomy. Patients were followed postoperatively for an average of 34 months (range, 14-126 months). The amount of ptosis was quantified pre- and postoperatively for seven of the nine eyelids that underwent ELA. For these seven eyelids (five patients), there was a statistically significant improvement in the mean interpalpebral eyelid fissure height from 3.7 mm preoperatively to 7.8 mm postoperatively, with a mean difference of 4.1 mm (95% confidence interval 1.9 mm to 6.25 mm, p = 0.0038). Postoperative complications included worsened diplopia in one patient with ELA and exposure keratopathy in one patient with frontalis sling. Two of the ELA eyelids developed recurrent ptosis requiring additional surgery more than 2 years after the initial procedure. CONCLUSIONS: Blepharoptosis surgery can achieve eyelid elevation in patients who have failed to respond to medical therapy for MG. Potential complications include worsened diplopia and exposure keratopathy.     

Use of 0.5% apraclonidine solution in evaluation of blepharoptosis

PURPOSE: To evaluate the effect of instillation of a specific alpha2-adrenergic agonist, topical 0.5% apraclonidine solution, on upper eyelid position in patients with blepharoptosis. METHODS: This study included 45 eyelids of 35 adult patients with blepharoptosis. Of these, 37 eyelids had acquired ptosis and 8 had congenital ptosis. Palpebral fissure height and margin-reflex distance in the upper eyelid were measured before and after instillation of 0.5% apraclonidine, 2.5% phenylephrine, and both drugs. RESULTS: After instillation of 2.5% phenylephrine, 0.5% apraclonidine, and both drugs, the mean increases in palpebral fissure height were 2.12 mm+/-1.4 mm, 2.11 mm+/-1.4 mm, and 2.26 mm+/-1.3 mm, respectively, and the mean increases in margin-reflex distance were 1.93 mm+/-1.2 mm, 1.89 mm+/-1.3 mm, and 2.03 mm+/-1.2 mm, respectively (p=0.86 and p=0.85). The apraclonidine solution did not alter the test results in 14 eyelids in which the phenylephrine test results were negative. CONCLUSIONS: Topical 0.5% apraclonidine solution can be as effective as topical 2.5% phenylephrine in elevating a ptotic upper eyelid, and may be used for preoperative evaluation of blepharoptosis. Combined use of both drugs may not provide any additional benefit.     

Upper eyelid motility in blepharoptosis and in the aging eyelid

PURPOSE. To study the metrics of lid saccades in blepharoptosis and to distinguish any differences in the dynamics of eyelid movements that are related to the cause of blepharoptosis and to aging. METHODS. The lid and vertical eye saccades of 7 patients with congenital blepharoptosis and those of 18 patients with aponeurogenic blepharoptosis, either involutional or rigid-contact-lens-induced, were recorded with electromagnetic search coils. For each saccade, two parameters were assessed: amplitude and peak velocity. Two age-matched control groups were assessed in the same manner. Repeated measures analysis of variance was used to investigate any observed differences between the included groups. RESULTS. Congenital and rigid-contact-lens-induced blepharoptosis were readily distinguishable from one another, as well as from the age-matched control group, in both lid saccadic amplitude and peak velocity. For example, 40 degrees downward lid saccades in the congenital blepharoptosis group averaged 22.9 degrees +/- 4.0 degrees (SD), whereas 30.0 degrees +/- 4.7 degrees lid saccades were made by the age-matched control group. The subjects in the two groups with aponeurogenic blepharoptosis also made lid saccades that were distinctive for their group (P: < 0.02), in both amplitude and peak velocity. For 40 degrees downward saccades in involutional and rigid-contact-lens-induced blepharoptosis, lid saccadic amplitude averaged 32.7 degrees +/- 4.3 degrees and 40.3 degrees +/- 3.5 degrees, respectively. Lid saccadic peak velocity declined significantly with age. Lid saccadic peak velocity for 40 degrees upward saccades in the younger control group averaged 401.7 +/- 11.4 deg/sec, whereas the older control group achieved an average peak velocity of 360.7 +/- 60.4 deg/sec. The lid saccadic dynamics in the involutional blepharoptosis group proved to be similar (P: > 0.05) in saccadic amplitude and peak velocity to those of age-matched controls. CONCLUSIONS. In different forms of blepharoptosis, distinctive metrics of lid saccades occur. The current data suggest that involutional blepharoptosis is not a consequence of normal age-related changes in eyelid function.     

Upper blepharoplasty: a novel approach to improving progressive myopathic blepharoptosis

OBJECTIVE: To describe the results of upper blepharoplasty for the treatment of progressive myopathic upper eyelid blepharoptosis. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Six consecutive patients treated bilaterally. INTERVENTION: Upper blepharoplasty in 6 patients (12 eyelids) with progressive myopathic ptosis. MAIN OUTCOME MEASURES: Subjective visual improvement, ocular comfort, preoperative and postoperative margin reflex distances, lagophthalmos, and degree of corneal keratopathy at last follow-up date. RESULTS: All patients had subjective visual improvement and denied ocular discomfort. Upper eyelid ptosis, measured by margin reflex distances, was improved. No worsening of lagophthalmos or corneal keratopathy was noted. CONCLUSIONS: Upper blepharoplasty may be an excellent alternative for ptosis treatment in patients with progressive myopathies. Improvement in ptosis, margin reflex distance, without concomitant lagophthalmos, and corneal keratopathy can be achieved.