Dehiscence and disinsertion of the aponeurotic bundle of the upper eyelid levator in acquired ptosis

Aponeurotic defects and disinsertion of the levator aponeurosis are responsible for many cases of acquired ptosis. The typical clinical findings in aponeurotic defects are: history of prior orbital swelling, injury, ocular surgery, blepharochalasis; good to excellent levator function, thinning of the eyelid above the tarsus, high to absent lid crease, and normal Müller's muscle function. The purpose of the treatment is to repair a defect or advance the aponeurosis onto the tarsus. Levator aponeurosis surgery was used to treat 18 upper eyelids with acquired ptosis. Local anesthesia and surgery from an anterior approach were used in all cases. The advantages of this technique are: The lid height is determined by asking the patient to look in various fields of gaze. A blepharoplasty can be performed when necessary. The lid crease is formed. The exposition of the levator aponeurosis disinsertion is easier to recognize.     

Involutional ptosis

Aponeurotic defects and disinsertion of the levator aponeurosis are responsible for acquired involutional ptosis. The typical clinical findings in aponeurotic defects are high or moderate ptosis, good to excellent levator function, thinning of the eyelid above the tarsus, high to absent lid crease, and normal Müller's muscle function. The purpose of the treatment is to repair the defect or to advance the aponeurosis on the tarsus. This surgery can be done via the anterior approach with aponeurotic surgery or via the posterior approach with Müller's muscle conjunctival resection. In all cases, upper lid blepharoplasty is down.     

Ptosis following radial keratotomy. Performed using a rigid eyelid speculum

Seven patients with acquired ptosis and normal levator function following anterior radial keratotomy are presented. Five of these patients then elected to undergo radial keratotomy of the opposite eye, and four had symmetrical lid fissures (mild bilateral ptosis) after bilateral surgery. Ptosis is a well-known complication of cataract extraction, but has not been reported following radial keratotomy. Unlike cataract extraction, radial keratotomy does not require anesthetic injections, bridle sutures, or conjunctival flaps. The rigid Knapp eyelid speculum used in these cases remains as the only apparent cause of eyelid trauma and subsequent ptosis. During radial keratotomy, the speculum was opened widely in order to provide good corneal exposure and avoid contact with the diamond knife. Contraction of the orbicularis oculi muscle against the rigid speculum may have traumatized the lid, resulting in a levator aponeurosis disinsertion and subsequent ptosis.     

The Aponeurotic Approach to Eyelid Retraction

A technique for the upper lid retraction that involves an anterior approach similar to aponeurotic ptosis surgery is presented. Instead of advancing the aponeurosis, it is recessed and Moller's muscle is completely extirpated. The lateral horn of the levator must be cut to relieve the marked temporal elevation of the eyelid. Lid height and contour are adjusted intraoperatively with patient cooperation. In the lower lid, the retractors are recessed via a conjunctival approach unless simultaneously performed with orbital decompression. Any amount of lid retraction may be corrected by this technique in the upper lid and up to 3 mm of lower lid retraction can be corrected. Lid height in both the upper and lower lid is lasting and predictable. Thirty-one patients (63 eyelids) have been operated on using this technique with good results. Results in 17 patients (35 eyelids) with follow-up ranging from 8 to 42 months are presented.     

INVOLUTIONAL PTOSIS: RECOGNITION AND MANAGEMENT

Involutional ptosis is a ptosis of varying degree. There is good levator function with a high lid fold and increased lid excursion on downgaze. There may be increased translucency of the upper lid. We reviewed all adult ptosis cases over the past three years at Sydney Eye Hospital and found 20 cases to have aponeurotic defects such as a dehiscence or disinsertion. Ninety percent of our cases had a positive 10% phenylephrine test.
We recommend that all operations be done under local anaesthesia without adrenaline, overcorrecting by 1–2 mm at the time of surgery.     

Acquired ptosis: dehiscences and disinsertions. Are they real or iatrogenic?

Acquired ptosis has previously been felt to be due to a dehiscence or disinsertion of the levator aponeurosis. In the early years of levator surgery, the aponeurosis was often exposed by using blunt dissection. We have found that with a change in surgical technique, which eliminates blunt dissection, the incidence of aponeurotic defects decreases dramatically. Dehiscence and disinsertion may therefore be caused by traumatic surgical dissection of an attenuated aponeurosis.     

Association of entropion with cataract surgery

Ptosis may develop after cataract surgery because of a dehiscence of the levator aponeurosis. A series of patients undergoing entropion repair was examined in order to determine the mechanism of entropion and the correlation with cataract surgery. It is suggested that involutional senile entropion may develop related to cataract surgery, on the same basis as ptosis, due to disinsertion of the capsulopalpebral fascia. It is suggested that the cataract surgeon should examine the patient closely for preoperative entropion to prevent or anticipate the development of frank entropion after the cataract surgery.     

Acquired ptosis secondary to vernal conjunctivitis in young adults

PURPOSE: To establish a relation between prolonged severe vernal conjunctivitis and upper eyelid ptosis. METHODS: The study consisted of 12 patients between the ages of 19 and 32 years with acquired ptosis who presented in our clinic between September 2001 and February 2005. Potential factors responsible for acquired ptosis were investigated in all patients, with specific attention to the history and severity of vernal conjunctivitis. RESULTS: We found vernal conjunctivitis to be the identifiable cause in 8 men and 4 women with acquired ptosis. There was neither contact lens usage nor trauma or ocular surgery history in their medical records. The blepharoptosis was caused by levator disinsertion and recession of the aponeurosis. The pathology improved in each case after reattachment of the aponeurosis to the superior tarsal border. CONCLUSIONS: These findings suggest that prolonged severe vernal conjunctivitis may induce a lower position of the upper eyelid and eventually lead to ptosis through levator disinsertion that is similar to involutional ptosis. We believe that chronic inflammation of the upper eyelid with giant papillary conjunctivitis and persistent rubbing of the eyelids may be responsible for the development of this pathology.     

Ptosis surgery: anterior approach for levator aponeurosis shortening (author's transl)

A simplified method for ptosis surgery has been used in 33 patients. The levator aponeurosis is exposed by the anterior approach. It is folded or excised and reattached to the anterior surface of the tarsus, matching the level and the contour of the two upper lids. The cosmetic appearance of the lid is improved by the skin closure technique. This method for ptosis surgery meets the anatomical and physiological needs best. It has given very satisfactory functional and cosmetic results.     

Dehiscence of levator aponeurosis in ptosis after sub-Tenon injection of triamcinolone acetonide

Objective: To report the incidence, intraoperative findings, and surgical outcome of secondary ptosis that developed after a sub-Tenon injection of triamcinolone acetonide (TA).Study Design: Retrospective, cross-sectional study.Participants: One hundred forty-seven cases with a total of 286 sub-Tenon TA injections.Methods: The medical records of 163 eyes of 147 cases treated with a sub-Tenon injection of 10 mg or 20 mg TA were reviewed. The incidence of secondary ptosis (palpebral fissure >2 mm narrower than that of the fellow eye) after a sub-Tenon TA injection was determined. The preoperative levator function and margin reflex distance (MRD) of the affected eyes, and the intraoperative findings in eyes that underwent reconstructive surgery, were evaluated.Results: Eight eyes (5%) developed secondary ptosis after the injection and 6 eyes were treated by reconstructive surgery. The preoperative levator function of the affected eyes did not differ from that of the fellow eyes. Intraoperatively, no septal disruption or fat herniation was noted, but an aponeurotic disinsertion was identified and repaired with an advancement of the leading edge to the anterior tarsal plate. The surgery led to satisfactory results, with improvement of the MRD from −1.3 (SD 1.5) mm preoperatively to 2.3 (SD 0.5) mm postoperatively (p = 0.027). Additional sub-Tenon TA injections were required in 2 eyes after eyelid surgery but the ptosis did not worsen.Conclusions: A sub-Tenon TA injection can occasionally cause ptosis by inducing a disinsertion of the levator aponeurosis. However, surgical reconstruction can lead to successful resolution of the ptosis.     

Visible iris sign as a predictor of problems during and following anterior approach ptosis surgery

Objective

To describe the pre- and postoperative features of the visible iris sign (VIS), which is the apparent visibility of iris colour through a closed upper eyelid, in patients undergoing anterior approach surgery for severe involutional aponeurotic ptosis, and to assess its effect on postoperative outcome.

Design

Prospective, comparative interventional case series.

Methods

Prospective series of all patients undergoing surgery for severe involutional aponeurotic ptosis during a 16-month period at a single centre.

Inclusion criteria

Severe involutional ptosis (upper eyelid margin reflex distance (MRD) ≤1 mm) treated by anterior-approach surgery.

Main outcome measures

Presence of VIS, type of ptosis (primary or recurrent), preoperative MRD, levator function and skin crease height, documented unusual intra-operative findings, postoperative complications, and follow-up time.

Results

Of 133 procedures for involutional aponeurotic ptosis, 96 procedures (56 patients) were included in the study. In total, 12 patients (21%, 12/56, 2 males, and 10 females) had been identified as having VIS preoperatively. In order to avoid any selection bias, only patients with severe degree of ptosis were included in the two groups with the two groups being alike in the preoperative lid height, levator function or the skin crease. In the VIS group, 55% (12/22) had a thinned, significantly retracted levator aponeurosis and a thin tarsus prone to full-thickness suture passes (36.3%, 8/22) during aponeurosis reattachment. Immediate persistent overcorrection during surgery was seen in three procedures, with one patient having an under corrected outcome when treated with a hang-back suture. In the non-VIS group, no patients were documented intra-operatively, as having significant retraction of the levator aponeurosis. However, 14% (10/74) of the eyelids were recorded as having a very attenuated levator and one patient (3%, 1/44) was noted to have a floppy tarsus that was difficult to suture. The total incidence of intra-operative difficulties during surgery were 78% in the VIS group and 22% in the non-VIS group. Mean postoperative follow-up was 22 weeks. (median 18, range 12–64). The overall success rates were 63.6% (14/22) in the VIS group, compared with 77.0% (57/74) in the non-VIS group (P=0.260). After excluding cases undergoing concurrent blepharoplasty and non-caucasions, success rates were 57.1% (4/7) and 69.2% (9/13) in the VIS and non-VIS groups, respectively (P=0.598). All failures were because of under-correction.

Conclusion

The VIS is a clinical sign of severe involutional ptosis. Patients with VIS have one or more features, including a retracted levator aponeurosis, a thinned tarsus prone to full-thickness suture passes, and a tendency for immediate persistent overcorrection following levator advancement. Preoperative identification of VIS may help in appropriate patient counselling, procedure selection, anticipation of intraoperative difficulties, and possibly further standardisation of future cohorts when evaluating the results of involutional ptosis surgery.

Précis

The authors describe the pre-, intra- and postoperative features of visible iris sign. They discuss the success rates of anterior approach surgery in VIS patients and discuss the contributing factors for a poorer outcome.     

外路法上睑提肌缩短治疗瘢痕性上睑下垂

目的探讨外伤或义眼台取出术后致上睑提肌瘢痕粘连所致上睑下垂的手术治疗。方法8例（8眼）采用外路法上睑提肌缩短前徙术治疗因上睑提肌瘢痕粘连所致的上睑下垂，术中充分游离上睑提肌腱膜。结果8例（8眼）睑裂高度与对侧眼基本一致，上睑弧度自然，义眼台术后的上睑下垂稍小于对侧眼效果更好。结论外路法上睑提肌缩短前徙可有效治疗上睑提肌瘢痕粘连所致上睑下垂。     

外路腱膜修复术治疗老年性上睑下垂

目的 研究老年性上睑下垂的发病机制、临床特征和手术方法。方 法对21例27眼，采用外路腱膜修复术，术中根据腱膜的损伤程度采取不同的修复方法。结果 经6个月～2年的随访观察，效果达90％以上，患者均很满意。结论 外路腱膜修复术是治疗老年性上睑下垂的有效方法。     

提上睑肌中央腱膜切断术治疗甲状腺相关眼病上睑退缩

目的：评估提上睑肌中央腱膜切断术矫正甲状腺相关眼病上睑退缩的临床疗效。方法：对35例52眼以上睑退缩为主要表现的静止期甲状腺相关眼病患者采用提上睑肌中央腱膜切断术矫正退缩的上睑,并观察其临床疗效。结果：术后所有患者上睑退缩均得以矫正,自觉症状不同程度减轻或消失。结论：提上睑肌中央腱膜切断术能有效矫正甲状腺相关眼病的中度上睑退缩。     

Aponeurotic ptosis repair under local anesthesia. Prediction of results from operative lid height

The unpredictability of acquired ptosis repair is a difficult problem. Aponeurotic ptosis repair may be performed under local anesthesia, and past reports have suggested that operative lid position may be used to predict the final result. The authors prospectively studied 20 aponeurotic repairs under local anesthesia for patients with acquired ptosis and normal levator function. Photographs were taken during surgery, 1 week after surgery, and 3 months after surgery. Statistical analysis of vertical lid fissure measurements demonstrated a linear relationship between operative lid position and the 3-month result. When operative lid height was significantly greater than 10 mm, then a slight postoperative rise was observed, but when operative lid height was significantly less than 10 mm, then a slight postoperative fall was observed. Lid position at 1 week proved to be an excellent predictor of the 3-month result, establishing a reasonable basis for intervention in cases of overcorrection or undercorrection.     

Acquired ptosis associated with a conjunctival cyst

A 44-year-old woman with a history of previous ptosis surgery presented with a moderate ptosis of the left upper eyelid and a large cystic mass extending over the length of that lid. The mass was excised completely and histologically found to be a conjunctival ductal cyst. The levator aponeurosis was disrupted by the cyst and required reconstruction. This case demonstrates an acquired ptosis associated with a large conjunctival cyst as a late complication of ptosis surgery.     

Involutional ptosis: recognition and management

Involutional ptosis is a ptosis of varying degree. There is good levator function with a high lid fold and increased lid excursion on downgaze. There may be increased translucency of the upper lid. We reviewed all adult ptosis cases over the past three years at Sydney Eye Hospital and found 20 cases to have aponeurotic defects such as a dehiscence or disinsertion. Ninety percent of our cases had a positive 10% phenylephrine test. We recommend that all operations be done under local anaesthesia without adrenaline, overcorrecting by 1-2 mm at the time of surgery.     

Severe congenital horizontal tarsal kink without levator aponeurosis disinsertion

A newborn presented with congenital severe tarsal kink of the upper eyelids not caused by levator aponeurosis disinsertion. A bilateral anterior lamellar repositioning procedure was performed to correct the tarsal kink. Levator aponeurosis disinsertion was not observed as an intraoperative finding. The tarsal kink disappeared, and eyelid positions remained stable during a follow-up period of 1 year. Our case indicates that severe congenital tarsal kink may develop without levator aponeurosis disinsertion, and anterior lamellar repositioning technique is a simple and effective method of treatment.     

A single technique to correct various degrees of upper lid retraction in patients with Graves' orbitopathy

BACKGROUND: Several lengthening techniques have been proposed for upper eyelid retraction in patients with Graves' orbitopathy and variable rates of success have been reported. Most authors recommend different procedures for different degrees of retraction, but cannot prevent residual temporal retraction in a significant number of cases. The modified levator aponeurosis recession described by Harvey and colleagues, in which the lateral horn is cut completely, seems to be an exception to this rule, but was evaluated in a limited number of cases only. METHOD: The authors further modified Harvey's technique by dissecting the aponeurosis together with Müller's muscle of the tarsus and the conjunctiva medially only to the extent necessary to achieve an acceptable position and contour of the eyelid in upright position. They also used an Ethilon 6.0 suture, instead of Vicryl, on a loop. It is placed between the tarsal plate and the detached aponeurosis to prevent spontaneous disinsertion. This modification was used in 50 Graves' patients (78 eyelids) with a upper lid margin-limbus distance ranging from 1 to 7 mm and evaluated using strict criteria. RESULTS: A perfect or acceptable result was obtained in 23 of 28 patients (82%) with bilateral retraction and in 18 of 22 patients (82%) with unilateral retraction. Seven eyelids were overcorrected (too low) and three undercorrected, necessitating reoperation. All other eyelids had an almond-like contour and a lid crease of 10 mm or less. No complications except subcutaneous haematomas were seen. Two patients showed a recurrence of lid retraction 9 months after the operation. CONCLUSION: This technique is safe and efficacious and can be used for all degrees of eyelid retraction.     

先天性上睑下垂患者提上睑肌腱膜的病理改变

背景先天性上睑下垂是临床常见的眼睑运动功能障碍性疾病,可导致患者视功能异常。国外研究表明,提上睑肌的发育异常与该病的发生明显相关,但中国人群该病患者提上睑肌的形态研究缺乏。目的对先天性上睑下垂患者提上睑肌腱膜组织进行组织病理学检查,探讨其发育异常的具体表现。方法先天性上睑下垂患者（年龄14～19岁,平均17岁）2l例,根据上睑下垂的程度分为轻度组（3例）、中度组（14例）和重度组（4例）,在提上睑肌缩短术过程中获取所有患眼截除的提上睑肌腱膜组织标本,分别进行苏木精一伊红染色、Masson三色染色、胶原纤维染色,对标本中的Ⅲ型胶原蛋白和肌球蛋白行免疫组织化学染色,患者标本的染色结果与取自北京同仁医院眼库的9例正常供体的新鲜提上睑肌腱膜组织进行对照。结果不同程度先天性上睑下垂患者随着下垂程度的增加,提上睑肌腱膜肌纤维数量减少,间质中结缔组织增加,肌内膜的完整性下降的例数均增加,各组间比较差异均有统计学意义（Z=-0．702,P=0．002;Z=0．738,P‘0．001;Z=0．746,P〈O．001）。4例（占19％）先天性上睑下垂患者标本中发现肌间质中有脂肪细胞增生。免疫组织化学染色发现,先天性上睑下垂患者组提上睑肌腱膜肌纤维中肌球蛋白的表达较正常对照组明显减弱,而Ⅲ型胶原蛋白的表达明显增强。先天性上睑下垂患者组标本中肌动蛋白、肌红蛋白、纤维连接蛋白、Ⅳ型胶原纤维及层黏连蛋白的表达强度与正常对照标本比较差异均无统计学意义（P〉O．05）。结论先天性上睑下垂患者提上睑肌腱膜组织肌纤维、结缔组织及其相关蛋白均有发育异常,其病理改变的程度与症状一致。