Long-term results of autogenous palmaris longus frontalis sling in children with congenital ptosis

PURPOSE: To investigate the long-term outcome of using autogenous palmaris longus tendon (PLT) sling for correcting congenital ptosis in children. METHODS: This is an observational case series involving 15 eyelids of 14 consecutive children with congenital ptosis who underwent frontalis suspension surgery using PLT in a university teaching hospital. RESULTS: One child had bilateral ptosis and the other children had unilateral ptosis. The age of patients at the time of surgery ranged from 2 to 7 years, with an average of 4.7 years. At a mean follow-up of 92 months (range, 80-104 months), all eyelids were successfully corrected with good lid height. No recurrence or other postoperative complications were encountered except one patient who developed a small skin fold over the PLT harvest site.CONCLUSION: Long-term lid position is remarkably stable after surgical correction using PLT. PLT sling appears to be a safe and effective treatment for children with congenital ptosis requiring frontalis sling operation. It could be a good alternative to autogenous fascia lata, and further studies, to compare these two sling materials seem warranted.     

先天性上睑下垂379例治疗体会

目的 应用不同术式治疗先天性上睑下垂,并对手术效果及其并发症进行评价.方法 自2002年6月至2007年10月间,共收治先大性上睑下垂患者379例(460只眼).其中重度上睑下垂300例(381只眼),中度上睑下垂47例(47只眼),轻度上睑下垂32例(32只眼).行阔筋膜悬吊术196例(246只眼),额肌瓣悬吊术104例(135只眼),提上睑肌缩短术47例(47只眼),提上睑肌腱膜折叠术32例(32只眼).结果 术后满意率为94.6%,好转率为5.0%,总有效率为99.6%.其中阔筋膜悬吊术手术满意率为91.9%,额肌瓣悬吊术满意率为95.5%,提上睑肌缩短术满意率为95.7%,提上睑肌腱膜折叠术满意率为96.9%.手术后有50只眼(10.9%)出现各种并发症,主要有额部血肿、暴露性角膜炎、矫正不全和上穹隆结膜脱垂,经相应处理后均好转.结论 对于提上睑肌无力的重度上睑下垂患者,采取阔筋膜悬吊术或额肌瓣悬吊术治疗,术后重睑自然,远期外观效果较好.提上睑肌力较好的轻度上睑下垂患者宜采取提上睑肌手术,术后重睑弧度自然,并发症少,是较理想的治疗方法.     

先天性上睑下垂379例治疗体会

目的 应用不同术式治疗先天性上睑下垂,并对手术效果及其并发症进行评价.方法 自2002年6月至2007年10月间,共收治先大性上睑下垂患者379例(460只眼).其中重度上睑下垂300例(381只眼),中度上睑下垂47例(47只眼),轻度上睑下垂32例(32只眼).行阔筋膜悬吊术196例(246只眼),额肌瓣悬吊术104例(135只眼),提上睑肌缩短术47例(47只眼),提上睑肌腱膜折叠术32例(32只眼).结果 术后满意率为94.6%,好转率为5.0%,总有效率为99.6%.其中阔筋膜悬吊术手术满意率为91.9%,额肌瓣悬吊术满意率为95.5%,提上睑肌缩短术满意率为95.7%,提上睑肌腱膜折叠术满意率为96.9%.手术后有50只眼(10.9%)出现各种并发症,主要有额部血肿、暴露性角膜炎、矫正不全和上穹隆结膜脱垂,经相应处理后均好转.结论 对于提上睑肌无力的重度上睑下垂患者,采取阔筋膜悬吊术或额肌瓣悬吊术治疗,术后重睑自然,远期外观效果较好.提上睑肌力较好的轻度上睑下垂患者宜采取提上睑肌手术,术后重睑弧度自然,并发症少,是较理想的治疗方法.     

Suspending of blepharoptosis on temporalis fascia slings: our own experience

There are many procedures providing treatment of ptosis. In cases with palpebrae levator palsy, procedures involving mechanical suspension of palpebrae are used. Artificial and natural materials are used to suspend the lid. We describe surgical treatment of blepharoptosis using autogenous temporalis fascia sling. The sling is attached to the tarsus and spreads to the frontalis muscle. We have used this procedure in 12 cases. Full effect of functional elevation of palpebrae was achieved in 14 to 30 days after procedure. We did not encounter any significant complications due to this material. These operative modifications make this procedure more closely parallel to the normal eyelid dynamics and provide consistently good results for this difficult problem.     

Transconjunctival frontalis suspension: a clinical evaluation.

PURPOSE: To determine the effectiveness of transconjunctival frontalis suspension in patients with blepharoptosis and poor levator function (eyelid excursion less then 5 mm). METHODS: The medical records of 29 patients (50 ptotic eyelids) were reviewed. RESULTS: Four patients (eight eyelids) had blepharophimosis syndrome, ten patients (27 eyelids) had congenital ptosis, seven patients (14 eyelids) had myogenic ptosis, and one patient (one eyelid) had neurogenic ptosis. Surgical results were good and complications were minimal during follow-up intervals ranging from six months to seven years. CONCLUSIONS: Transconjunctival frontalis suspension is technically simpler than traditional external frontalis suspension and yields satisfactory functional and cosmetic results in patients with poor levator function.     

Blepharoptosis correction with frontalis suspension using a supramid sling: duration of effect

PURPOSE: To investigate the duration of effect after frontalis suspension with a Supramid (S. Jackson, Inc, Alexandria, Virginia) sling. METHOD: We reviewed 81 consecutive patients (40 males, 41 females), aged 6 months to 50 years (mean, 12 years) with upper eyelid blepharoptosis who underwent frontalis suspension with Supramid sling surgery at a major eye center. RESULTS: Fifty patients had unilateral and 31 patients had bilateral blepharoptosis repair. Forty-three (53%) of the 81 patients had postoperative follow-up of 3 to 12 years; all these patients had a recurrence of blepharoptosis to the preoperative level 1 to 18 months postoperatively. CONCLUSION: Blepharoptosis correction with frontalis suspension with Supramid sling has a temporary effect, and use of this procedure for blepharoptosis correction should be discouraged.     

Exposure keratopathy following silicone frontalis suspension in adult neuro‐ and myogenic ptosis

Purpose: To evaluate the incidence of exposure keratopathy following silicone frontalis suspension in adult neuro‐ and myogenic blepharoptosis. Method: Retrospective noncomparative analysis of the charts of 69 cases (101 eyelids) of silicone frontalis suspension. Results: Sixty‐one patients (93 eyelids) had myogenic ptosis, and eight patients (eight eyelids) had neurogenic ptosis. Preoperative diagnoses included chronic progressive external ophthalmoplegia, myotonic dystrophy, oculopharyngeal dystrophy, third cranial nerve palsy because of trauma or other causes. Average age at the time of operation was 54. Mean interval between the intervention and the first and second postoperative control was 8 and 28 months, respectively. Thirty‐one patients (31 eyelids) needed a second follow‐up visit. Postoperative punctate epithelial erosions (PEE) were encountered most frequently in patients with Steinert’s disease (42% of eyes) and congenital ptosis (33% of eyes). Patients with oculopharyngeal dystrophy did not develop PEE. Corneal ulceration developed in three eyes (two patients): one eye was successfully treated with local antibiotic ointments and lubricants, a bilateral corneal ulceration in the second patient was successfully treated with partial conjunctival grafts. Conclusion: This study cohort demonstrated a 26% risk of exposure keratopathy following silicone frontalis suspension. The risk of major corneal complications, such as ulceration, was low (3%).     

后天性上睑下垂的手术治疗

目的探讨后天性上睑下垂的手术治疗方法和效果。方法对100眼后天性上睑下垂的手术治疗进行了回顾性总结。结果弗-盖氏术、Whitnall韧带悬吊术和提上睑肌腱膜瓣-额肌吻合术治疗神经源性和肌源性上睑下垂的手术成功率分别为41.6%、80%和90%。提上睑肌/腱膜修补术治疗外伤性和老年性上睑下垂的手术成功率分别为94.7%和100%。改良Hotz术治疗机械性上睑下垂的手术成功率为93.3%。结论根据上睑下垂的种类和程度选择适宜的手术方法和完善手术技巧是提高手术成功率的关键。     

Clinical evaluation of refractive changes following brow suspension surgery in pediatric patients with congenital blepharoptosis.

BACKGROUND AND OBJECTIVE: To evaluate the postoperative visual acuity and refractive changes occurring after bilateral frontalis brow suspension surgery in pediatric patients with congenital blepharoptosis. PATIENTS AND METHODS: Twenty-three patients between 4 and 12 years old with severe congenital blepharoptosis (unilateral in 21 cases and bilateral in 2 cases; total of 25 eyes) and poor levator function underwent bilateral frontalis brow suspension surgery by Crawford's double triangle method with 4:0 expanded polytetrafluoroethylene sutures. The non-ptotic eyes (21 eyes) undergoing frontalis brow suspension surgery served as the control group. All patients had best-corrected spectacle visual acuity (BCSVA) of more than 6/9 preoperatively in both eyes. Changes in the postoperative BCSVA, binocularity, relevant refractive parameters, lid position, lagophthalmos, lid lag, and tear break-up time were evaluated in both groups for 12 weeks and appropriate statistical tests were applied. RESULTS: Significant differences were found in the baseline characteristics and the postoperative changes in the eyes with and without ptosis. However, these were found to be transient and did not result in any new cases of amblyopia postoperatively. No complications requiring revision of surgery were seen. CONCLUSIONS: The changes in the BCSVA after frontalis brow suspension surgery are transient. Retinoscopy, manual keratometry, and corneal videokeratoscopy are simple and effective methods to evaluate the sequential refractive changes occurring in these eyes.     

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.     

Severe unilateral congenital ptosis with poor levator function: tarsoconjunctival mullerectomy plus levator resection vs frontalis sling procedure

AIM: To compare frontalis sling and tarsoconjunctival mullerectomy plus levator resection (TCMLR) in subjects with severe unilateral congenital ptosis with poor levator function (LF). METHODS: A prospective non-randomized non-blinded single center clinical trial. Fifty patients with severe unilateral congenital ptosis with poor LF were recruited. The frontalis sling and TCMLR were performed and the functional, cosmetic outcomes, complications, and success rate were evaluated at 1, 3, and 6mo postoperatively. The t-test, Chi-square, Fishers exact, and nonparametric Mann-Whitney tests were used by SPSS software. RESULTS: Frontalis sling and TCMLR procedures were performed on 26 and 24 patients respectively. The mean age was 10.97±10.67y. LF was significantly better in the TCMLR group at months 1, 3, and 6 (P=0.002). Lagophthalmos was more common in the TCMLR group (no significant difference). At month 3, mild punctate epithelial erosions were observed more in the frontalis sling group (P=0.002). Significant complete success rate of 1st and 6th month for the frontalis sling vs TCMLR groups were 50% vs 20.8% (P=0.02), and 38.4% vs 50% (P=0.03) respectively. CONCLUSION: Complete success rate of TCMLR is higher in long-term follow-up in contrast with the frontalis sling in the short-term. Transient complications are more detected in mid-term follow-ups in both groups.     

同种异体硬脑膜额肌悬吊术治疗儿童完全性上睑下垂

目的探讨同种异体硬脑膜应用于额肌悬吊术治疗儿童完全性上睑下垂的临床价值。方法将酒精处理后的同种异体硬脑膜作为悬吊中间材料，对21例(30眼)儿童完全性上睑下垂行额肌悬吊术。结果全部病例随访6～48个月，治愈率95．2％，未见感染、睑内外翻、睑缘畸形、倒睫、暴露性角膜炎、慢性肉芽肿等并发症。结论同种异体硬脑膜作为中间材料应用于额肌悬吊术治疗儿童完全性上睑下垂十分理想。     

Long-term results of frontalis suspension using autogenous fascia lata for congenital ptosis in children under 3 years of age

PURPOSE: To evaluate the outcome of frontalis suspension surgery for congenital ptosis using autogenous fascia lata for children under 3 years of age. DESIGN: Retrospective nonrandomized interventional case series. METHODS: This study included nine children (14 eyelids) with severe congenital ptosis aged less than 3 years. All patients underwent frontalis suspension surgery using autogenous fascia lata. Postoperative lid level results, ptosis recurrence, and cosmetic appearance of leg scars were evaluated after the operation. RESULTS: The mean age of the patients was 15.3 months (range, 6 months to 2.5 years) with a mean follow-up period of 41.6 months (range, 18 to 96 months). All children achieved satisfactory cosmetic and functional results, with no postoperative complications such as wound infection, corneal exposure, eyelid contour abnormalities, or ptosis overcorrection. No recurrence of ptosis was encountered. Harvesting was not difficult, and a sufficient amount of material was achieved. There was one patient (11.1%) with a hypertrophied leg scar. CONCLUSIONS: Frontalis suspension using autogenous fascia is proposed as a possible procedure for correcting congenital ptosis in children younger than 3 years of age. It appears to be an effective and feasible treatment for children with poor levator muscle function in this age group.     

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.     

Evaluation of polytetrafluoroethylene suture for frontalis suspension as compared to polybutylate-coated braided polyester

PURPOSE: To evaluate the efficacy of polytetrafluoroethylene (Gore-Tex) suture as compared to polybutylate-coated braided polyester (Ethibond) suture as sling materials for frontalis suspension in bilateral congenital ptosis. METHODS: Frontalis sling surgery by modified Crawford's double triangle technique was performed on 30 patients (60 eyes) with bilateral ptosis. The patients were randomized into two groups depending on the type of suture material used: polytetrafluoroethylene or braided polyester. RESULTS: Polytetrafluoroethylene suture achieved a statistically significant better and more stable ptosis correction, with slightly more lagophthalmos, than braided polyester suture over a mean (+/- SD) follow-up period of 16 +/- 3.24 months. There were more postoperative complications with braided polyester suture, but the difference was not statistically significant. CONCLUSION: This is the first clinical study in which polytetrafluoroethylene in the form of suture has been studied. Polytetrafluoroethylene suture was found to be a safe and effective sling material for frontalis suspension and it can be recommended for clinical use.     

Frontalis suspension sling using a silicone rod in patients affected by myogenic blepharoptosis

The charts of 10 patients affected by myogenic ptosis who underwent surgical correction by means of a frontalis suspension sling using a silicone rod were reviewed. The patients included in the study were affected by ptosis secondary to myasthenia gravis (MG), chronic progressive external ophthalmoplegia (CPEO) or mitochondrial myopathy (MM). In every patient the ptosis was severe (MRD( 1) < 2 mm), with the eyelid partially or totally occluding the visual axis; levator function was poor (<5 mm), Bell's phenomenon was poor or absent and the orbicularis function was reduced. Final eyelid height, patient satisfaction and the presence of complications were our main outcome measures. Analysis of the results showed that the ptosis was corrected in every patient with a clear visual axis. One patient with absent Bell's and poor levator function had exposure keratopathy resistant to medical treatment and required surgical revision. We believe that the frontalis suspension sling is safe, effective and is the procedure of choice for patients affected by poor-function acquired ptosis. A silicone rod, because of its elasticity, is the material of choice in this selected category of patients.     

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%).     

Frontalis muscle flap advancement with a pulley in the levator aponeurosis in patients with complete ptosis and deep-set eyes

PURPOSE: To offer an alternative to frontalis sling techniques to achieve a more horizontal traction vector force with the frontalis muscle flap. The proposed technique avoids malpositions such as pulling the upper eyelid in an anterior plane during maximum opening and ptosis of the eyelashes. METHODS: The technique, performed in 5 patients with complete unilateral ptosis and an absence of levator function, consisted of advancing a flap of frontalis muscle and creating a pulley with the aponeurosis of the levator muscle. Mean follow-up was 12 months. RESULTS: Ptosis was corrected in all 5 patients, with good aesthetic outcome. There were no cases of anterior eyelid advancement, entropion, or eyelash ptosis. The only complication was 1 case of lagophthalmos with corneal erosion. CONCLUSIONS: In this preliminary series, the technique was safe and effective for correcting severe blepharoptosis, with good aesthetic and functional results even in patients with deep-set eyes and without the eyelid malpositions that commonly occur in frontalis sling techniques.     

外伤性眶壁骨折伴上睑下垂矫治方法的改进--一期行高密度聚乙烯充填和额肌瓣悬吊术

目的 评价高密度聚乙烯(Medpor)作为填充物同期行额肌瓣悬吊术在治疗晚期眶壁骨折伴外伤性上睑下垂中的作用。方法 对眼眶壁骨折伴上睑下垂进行整复，术中使用Medpor人工材料充填修复眶壁缺损，以矫治眼球内陷和移位；同期行额肌瓣与上睑提肌远端吻合治疗外伤性上睑下垂。结果 1998年1月～2002年12月施行此手术7例，随访3～24月(平均9．8月)，显示整形后的眼眶眼睑外形良好，无感染、排异；其中7例原眼球内陷、下移均获得改善，7例睑裂宽度与健眼对称，3例复视消失，4例复视明显的改善。结论 Medpor是一种良好的眼眶骨缺损填充替代骨移植的人工材料，同期行额肌瓣与上睑提肌远端吻合治疗复杂眼眶骨折伴上睑下垂疗效确切。     

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.