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.     

Therapeutic Algorithm for Congenital Ptosis Repair with Levator Resection and Frontalis Suspension: Results and Literature Review

Background: Several treatments have been described for the treatment of congenital ptosis, but there are few studies that analyze the effectiveness of a therapeutic approach rather than a single technique. Aims: In this study, we aim to evaluate the effectiveness of our therapeutic algorithm, which relies on levator muscle resection and frontalis suspension with silicone rods, polytetrafluoroethylene (PTFE), or autologous fascia lata. Methods: We retrospectively analyzed all patients affected by congenital ptosis who underwent corrective surgery at a single department between January 1998 and January 2016. Results: A total of 116 procedures were performed in 86 patients, accounting for 35 levator resections, 67 frontalis suspensions, and 14 revisions. A satisfactory result was observed in 65 cases after one procedure (75.6%). Complications occurred in 13 cases after primary surgery (15.1%). Ptosis relapse was observed in 25 cases after primary procedure (21.5%). Frontalis suspension displayed a higher number of complications than levator resection (22.2% vs 3.1%, p=0.02). Conclusion: Our therapeutic algorithm was effective in 75.6% after one procedure. Frontalis suspension procedures encountered a higher rate of complication than levator resection. Fascia lata should be preferred to silicon rods whenever possible due to the lower recurrence rate. These issues confirm the therapeutic algorithm, although larger prospective studies are necessary to validate our approach.     

额肌瓣悬吊治疗外伤性上睑下垂

目的:评价额肌瓣悬吊术对外伤性上睑下垂的疗效。方法:对43例伤后6个月以上的外伤性上睑下垂病人行上睑额肌瓣悬吊术,平均随访时间18个月,观察其睑裂高度、上睑弧度、闭眼状态和角膜情况。结果:28例获得理想效果,13例获得显著效果,总有效率95.4％。结论:额肌瓣悬吊术是治疗外伤性上睑下垂的效果确切而安全的方法。眼科学报1997;13:107～108。     

Direct Tarsus to Frontalis Muscle Sling without Flap Creation for Correction of Blepharoptosis with Poor Levator Function

Purpose: To report the outcomes of ptosis surgery in patients with weak levator function utilizing the direct tarsus to frontalis muscle sling technique without creation of a flap.

Methods: In a prospective nonrandomized case series over a 3-year period, patients with ptosis and weak (less than 4?mm) levator function underwent direct sling of the tarsus to frontalis muscle without creating any flap. Success was defined as upper lid margin to central corneal reflex distance of at least 3?mm in bilateral cases and a difference of less than 1?mm in unilateral cases.

Results: Overall, 26 eyes of 22 patients with mean age of 15.4?±?9.4 years were operated and followed up for 13.5?±?8.4 months. The ptosis was congenital in 15 patients (68.2%) and acquired in 7 patients (31.8%). Twelve patients (54.5%) had a history of ptosis surgery. The procedure was judged as successful in 77.3% of patients after initial surgery and in 100% after reoperation. Surgical success after initial surgery was directly correlated with the amount of levator function (P?=?0.02). However, success was not associated with age (P?=?0.9) or history of surgery (P?=?0.9). None of the patients developed eyelid hematoma, lagophthalmus or dry eye.

Conclusions: Direct sling of the upper tarsus to the frontalis muscle without creation of flap is an effective procedure for correction of ptosis in patients with weak levator function. Minimal dissection and preservation of the orbicularis oculi prevents lagophthalmus and its consequences.     

Maximal Levator Muscle Resection for Primary Congenital Blepharoptosis with Poor Levator Function

Purpose: To evaluate the clinical outcomes of maximal levator muscle resection surgery in patients with poor levator function. Methods: This prospective study included 29 eyelids of 23 patients who underwent maximal levator resection surgery. Pre- and postoperatively, all patients’ routine ophthalmic examination including evaluation of upper eyelid skin crease positions; levator muscle function (LF), rima palpebrarum (RP), and margin-reflex distance (MRD) measurements were recorded. Outcome was considered successful when the difference between the two upper eyelids was ≤1?mm; if the difference between the two eyelid margins was more than 1?mm and less than 2?mm, it was considered to be satisfactory. More than 2?mm difference was considered to be poor. Results: Mean patient age was 11.3?±?8.6 years (3 months to 24 years). Mean follow-up time was 22.8?±?6.9 months (10 to 36 months). Preoperatively mean RP, MRD, and LF measurements were 5.5?±?1.7?mm, ?0.14?±?1.6?mm, 2.5?±?1.4?mm (0–4?mm), respectively. Preoperatively, eight (27,6%) patients had skin crease. Abnormal head posture was detected in eight (34.8%) of the patients. Postoperatively, RP, MRD, and LF values increased significantly (p?Conclusions: Maximal levator resection may be a good alternative method to frontalis suspension in congenital blepharoptosis patients with poor levator function.     

Congenital Ptosis: Results of Treatment Using Lyophilized Fascia Lata for Frontalis Suspensions

In a prospective collaborative study, congenital ptosis was repaired using lyophilized allogeneic fascia lata as the suspension material for frontalis sling procedures. Over 50 cases of unilateral and bilateral ptosis procedures were performed by pediatric ophthalmologists during the initial study period. No infections or evidence of tissue rejection were reported during a follow-up period of up to 24 months. Four failures, ascribed to slippage, were noted within the first several months and required regrafting. In an additional case, minimal slippage occurred, but resulted in satisfactory lid levels. All remaining cases achieved satisfactory cosmetic and functional results. Most collaborators found this form of preserved fascia lata to be superior to nylon polyfilament, cable-type suture. Clinical features of the patient population included a high incidence of strabismus (28%) and amblyopia (24%).     

Five-Year Follow-Up of a 30-Month Trial of Stability of Silicone Band Frontalis Suspension for the Treatment of Severe Unilateral Upper Eyelid Ptosis in Infants

Purpose: To evaluate the five-year stability of frontalis suspension of the upper eyelid with a silicone band for the treatment of severe congenital ptosis in infants. Methods: Chart review of pediatric patients with a follow-up of five years after unilateral frontalis suspension with silicone band was reviewed. Margin-reflex distance (MRD) and corneal staining were measured at different follow-up visits. Data were analyzed by analysis of variance and t test for paired data. Results: Twenty pediatric patients were included in this retrospective study. MRD was severely reduced before surgery in all cases: it ranged from ?1?mm to ?4?mm (?2.4?±?0.8?mm). After surgery, MRD increased to 2.9?±?0.3?mm, and then progressively decreased by 0.6?mm within the first three months (p?p?Conclusions: During the five-year follow-up of this retrospective study, the frontalis suspension with a silicone band proved to be a stable procedure. After 30 months from the first observation, MRD values were stable, except for two patients that underwent a second surgery to stabilize the worsening ptosis.     

Treatment of Congenital Ptosis with Frontalis Suspension: A Comparison of Suspensory Materials

One hundred forty-five consecutive frontalis suspension procedures performed during the years 1976 to 1982 at the Wills Eye Hospital for the repair of congenital ptosis were reviewed. Results with nylon polyfilament cabletype suture (Supramid Extra®) as the suspensory material were compared to results with allogenic fascia lata. Forty-nine of the 121 polyfilament cable-type suture procedures (40.5%) were considered failures either because of ptosis recurrence (28.1%) or granuloma formation (12.4%). Only two of 24 (8.3%) of the fascia lata cases failed. No granuloma was associated with the use of fascia lata. The clinical and pathologic characteristics of ptosis recurrence and suture-rejection granuloma formation are discussed. Available preparations of allogenic fascia lata are reviewed and suggested as alternatives to the use of nylon polyfilament cable-type sutures for the repair of congenital ptosis.     

额肌悬吊术治疗重度先天性上睑下垂的效果分析

目的 探讨在额肌筋膜瓣悬吊术中,行否睑轮匝肌桥瓣对手术效果的影响.方法 分析2003～2006年接受手术治疗的重度先天性上睑下垂患者,随机分为A组(术中做睑轮匝肌桥瓣)与B组(术中未做睑轮匝肌桥瓣),比较两组术后远期效果.结果 术后6个月比较,A组矫正满意42只眼,矫正良好7只眼,矫正不良2只眼;B组矫正满意51只眼,矫正良好6只眼,矫正不良0只眼,经Ridit检验两组差异有统计学意义(P＜0.01).结论 在额肌筋膜瓣悬吊术中,睑轮匝肌桥瓣对手术效果并无至关重要的作用,相反因其术后较多的产生局部粘连,可能使额肌筋膜瓣的活动性受到一定程度的限制.因此,不主张在该手术中采用睑轮匝肌桥瓣的做法.     

联合筋膜鞘悬吊术和额肌瓣悬吊术治疗中重度上睑下垂的疗效比较

目的:比较联合筋膜鞘悬吊术和额肌瓣悬吊术治疗中重度上睑下垂的临床疗效.方法:回顾性分析2013-03/2016-03在我院进行治疗的46例68眼中重度上睑下垂患者的临床资料,根据手术方法的不同分为研究组(23例34眼)和对照组(23例34眼),研究组行联合筋膜鞘悬吊术(conjoint fascial sheath,CFS),对照组行额肌瓣悬吊术,对两组患者上睑下垂矫正程度、上睑回退情况、满意度和并发症发生情况进行比较.结果:研究组治疗中重度上睑下垂的正矫率高于对照组,差异有统计学意义(P<0.05).治疗后研究组上睑回量明显低于对照组,差异有统计学意义(P<0.05).研究组对治疗的满意度高于对照组,差异有统计学意义(P<0.05).研究组并发症发生率明显低于对照组,差异有统计学意义(P<0.05).结论:联合筋膜鞘悬吊术治疗中重度上睑下垂具有很高的矫正率,并具有创伤小、并发症少和可重复性强等优点.     

两种先天性上睑下垂矫正术后眼表改变和恢复的差异研究

目的:探讨上睑提肌缩短术和额肌肌瓣悬吊术后眼表改变和恢复的差异。方法:对2007年1月至2007年4月在中山眼科中心住院的42例(62只眼)先天性上睑下垂患者,按手术方式和术后是否加用局部用药进行随机分组,观测各组术后2d、5d、7d和2周患者泪液的分泌、泪膜破裂时间、结膜充血、角膜荧光染色、睑板腺功能、瞬目次数、上睑睫毛角度和眼睑闭合情况,并分析其观察结果的差异是否有统计学意义。结果:3名患者(7·1%)因需要加用其它促角膜上皮生长的药物而退出本研究,其中1例(2.3%)因倒睫刺激角膜上皮水肿缺损需行手术调整,其余所有患者眼表检测项目的结果均显示不同程度地受到了手术影响,但是随着术后炎症的逐渐消退,这些受影响的眼表异常均会逐渐恢复正常。泪膜破裂时间、瞬目次数、眼睑闭合情况的影响在两种术式之间的差异有统计学意义,而在术后是否局部用药之间没有统计学差异;角膜荧光素染色在是否加用局部用药组之间有统计学差异,而不同术式之间没有统计学差异;泪液分泌量、结膜充血、睑板腺功能、睫毛角度则在所有组别之间均没有统计学差异。结论:两种上睑下垂的矫正术均会引起患者眼表的改变,额肌肌瓣悬吊术对泪膜破裂时间、瞬目次数、眼睑闭合情况影响的程度较大,而局部用药只能改善角膜荧光素染色异常、对其它眼表因素影响不大。上睑睫毛角度异常是引起角膜损害最危险的因素。眼科学报2007;23:219-226.     

超常量提上睑肌缩短及额肌瓣悬吊治疗重度先天性上睑下垂效果比较

目的：比较提上睑肌缩短术与额肌瓣悬吊术治疗重度先天性上睑下垂的疗效与并发症。

方法：对40例58眼重度先天性上睑下垂患者进行手术治疗,其中,20例28眼行额肌腱膜瓣悬吊术,20例30眼行改良的提上睑肌缩短术,术后随访6mo,观察两种手术方式治疗重度先天性上睑下垂的治疗效果及术后并发症的发生情况。

结果：术后随访6mo,提上睑肌缩短术组及额肌瓣悬吊术组治疗重度先天性上睑下垂的正矫率分别为：83%、82%,差异无统计学意义(P>0.05),但术后并发症的发生,如倒睫、闭合不全、暴露性角膜炎、结膜脱垂等,提上睑肌缩短术组少于额肌瓣悬吊术组,且有更好的外观。提上睑肌缩短术后6mo复诊时,眼睑闭合不全15眼,暴露性角膜炎共1眼,结膜脱垂2眼; 额肌瓣悬吊术后6mo随诊,眼睑闭合不全23眼,暴露性角膜炎2眼,上睑倒睫3眼。

结论：提上睑肌缩短术及额肌瓣悬吊术均能有效矫正重度先天性上睑下垂,但前者并发症少,术后外观好。     

A Randomised Controlled Trial to Compare Patient Satisfaction with Two Different Types of Local Anaesthesia in Ptosis Surgery

Background: Ptosis surgery is performed under local anaesthetic to allow intra-operative assessment of lid positioning. Most commonly the anaesthetic is administered as a subcutaneous infiltration at the surgical site. Ptosis surgery using a regional nerve block has also been described, with reported advantages for minimising levator paralysis and disruption of the surgical landmarks. This study was designed to compare patient satisfaction with the two techniques of local anaesthetic administration.

Methods: 32 patients undergoing ptosis surgery were enrolled into a randomised controlled trial to receive local anaesthetic either by subcutaneous infiltration or by regional nerve block. Patient satisfaction was measured postoperatively with a self-administered vertical response column questionnaire, the Iowa Satisfaction with Anaesthesia Scale (ISAS).

Results: Of the 32 patients who were recruited 3 patients were excluded from analysis due to incomplete questionnaires or deviation from the trial protocol. Patient groups were well matched in terms of age, sex, time on waiting list, anaesthetic risk score, and operating grade of surgeon. Comparison of ISAS scores with the Mann Whitney test demonstrated an equal level of patient satisfaction with the two techniques.

Conclusion: This randomised controlled trial found regional nerve blocks to be associated with equal levels of patient satisfaction as the more standard technique of diffuse infiltration of local anaesthetic along the upper eyelid. This result supports the use of regional nerve blocks as a valid alternative for anaesthesia in ptosis surgery.     

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.     

提上睑肌离断额肌瓣悬吊术治疗中重度Marcus-Gunn综合征的临床研究

目的研究提上睑肌离断额肌瓣悬吊术治疗中重度Marcus-Gunn综合征的临床疗效。方法6例中重度Marcus-Gunn综合征患者采用提上睑肌离断额肌瓣悬吊手术治疗。结果随访6个月～5年,6例患者术后颌动瞬目症状消除,双侧睑裂对称,上睑缘无遮盖瞳孔,睑缘弧度自然美观,2例伴有轻度的上下睑闭合困难及上睑迟滞现象。结论提上睑肌离断额肌瓣悬吊术是治疗中重度Marcus-gunn综合征较理想的手术方法。     

Clinical and Anatomical Substantiation of Levator Resection in the Complex Surgical Treatment of BPES

Objective: To describe the clinical and anatomical results of the complex one-stage surgical treatment of BPES by means of levator resection. Materials and Methods: 51 children (73 eyes) aged 3–16 years with BPES were operated on by the newly developed one-stage technique at the Pediatric Ophthalmology Department of the Filatov Institute of Eye Diseases and Tissue Therapy. The surgical technique included shortening of the internal canthal ligament, resection of the tarsus and levator muscle, and skin plasty. The new surgical technique is based on new data on the topography of the upper eyelid and anterior part of the orbit obtained by MRI—onward protrusion of the orbital septum with increased volume of the pre-aponeurotic fat pad; thickening of the suborbicularis fat layer; shortening and thickening of the mobile part of the upper eyelid; and slight expression and low position of the palpebral fold. Results: Elimination of ptosis and epicanthus was achieved in all cases (eye fissure widening of up to 7–11 mm, average 8.8 ± 1.04 mm, and lengthening of up to 21–30 mm, average 24.7 ± 2.87 mm). Increased levator function to 3–10 mm (average 5.6 ± 0.19 mm) was also achieved after surgery. Control MRI investigation confirmed the normalization of the topography of the eyelid and orbital structures. Conclusion: The newly developed surgical technique for BPES correction by means of levator resection permits one to obtain high cosmetic and functional results based on improvement of the topography of the upper eyelid and orbital structures.     

两种手术方式治疗中重度先天性上睑下垂的疗效比较

目的：评价上睑提肌缩短术(LS)和额肌筋膜悬吊术(FMFS)治疗中重度先天性上睑下垂的疗效。

方法：回顾性分析2014-01/2017-12于我院住院手术的中重度先天性上睑下垂患者145例188眼,根据手术方式分为LS组(55例71眼)和FMFS组(90例117眼)。术后随访观察两组患者的手术疗效及并发症发生情况。

结果：术后12mo,LS组和FMFS组的手术效果\〖满意率(20.0% vs 32.2%)、基本满意率(70.9% vs 60.0%)、不满意率(9.1% vs 7.8%)\〗无明显差异(U=-1.415,P=0.147),但年龄<5岁的患者中FMFS组满意率高于LS组(32.0% vs 8.7%),两组患者手术疗效有明显差异(U=-2.244,P=0.025)。本组患者手术并发症均发生于术后1～15d,其中结膜脱垂仅发生于LS组(11例11眼),眼睑血肿仅发生于FMFS组(4例4眼),暴露性角膜炎、睑内翻倒睫、睑缘畸形、睑球分离在两组患者中均有发生。

结论：LS术和FMFS术对中重度先天性上睑下垂均有良好的矫正效果,FMFS术在5岁以下患者中手术满意率更高。     

Clinical value of phenylephrine testing in the upper and lower eyelids of patients with aponeurotic and congenital eyelid ptosis

AIM: To characterize the phenylephrine test in aponeurotic and congenital eyelid ptosis, to determine the appropriate timing of the phenylephrine test, and to assess the responses of the upper and lower eyelids. METHODS: This was a retrospective analysis of 140 eyes of 87 patients (mean age 52.29±16.45y; 22 males, 65 females) with upper eyelid ptosis. Totally 88.6% had aponeurotic and 11.4% had congenital ptosis. For the evaluation of the responses of the upper and lower eyelids to topical 2.5% phenylephrine, the scleral show height, the marginal reflex distance (MRD) between the inferior margin of the upper eyelid and pupillary light reflex (MRD1), and between the central portion of the lower eyelid and pupillary light reflex (MRD2) were measured at the 2nd, 5th, and 15th minutes. The changes of MRD1 and MRD2 with time (ΔMRD1 and ΔMRD2) were evaluated. RESULTS: The mean MRD1, MRD2, and scleral show heights increased within 5min after testing, remaining largely stable between the 5th-15th minutes. The percentage of eyes with a greater response in MRD1 increased with increased severity of ptosis (P<0.05). Eyes with aponeurotic ptosis were more responsive to phenylephrine testing than congenital ptosis. The mild ptosis group had lower scleral show measurements and higher ΔMRD2 values. The ΔMRD1 and ΔMRD2 values were poorly correlated in all measurement times. CONCLUSION: Performing the phenylephrine test 5min after instilling the reagent is adequate to assess the maximum response of the upper and lower eyelids. The upper and lower eyelid responses in phenylephrine testing are poorly correlated. However, the ΔMRD2 is related with baseline scleral show degree that may be a postoperative predictive factor. Further studies are necessary to determine the relationship between the responses of the lower eyelids to phenylephrine testing.     

Clinical,biochemical and histological results of a levator muscle transposition for ptosis in Cynomolgus monkeys

The transposition of the levator muscle of the upper lid on the frontal muscle was studied on four Macaque cynomolgus monkeys. The results indicate a re-innervation of the transposed levator muscle from nerve fibres of the frontal muscle. This operation introduces a new alternative to the treatment of ptosis with synkinesia of Marcus Gunn.