Sruti S. Akella , Jinesh Shah & Anne Barmettler
Sinus pericranii (SP) is a rare malformation involving aberrant connections between the dural venous sinuses and extracranial veins. Classically considered congenital pathology, there are reported instances of post-traumatic SP in adults. Very rarely, the upper eyelid is involved and the resulting ptosis can obstruct the visual axis. In these cases, surgical removal may be warranted. Because of the high risk of massive intraoperative hemorrhage, careful preoperative identification and diagnostic workup is essential. The authors report a patient with new onset, asymmetric eyelid ptosis referred for evaluation, and subsequently diagnosed with SP. Through a multi-disciplinary assessment, deferring surgical intervention was determined to be appropriate management. The lesion was monitored clinically, and at 6 months follow-up, there were no noted adverse outcomes.
Ozturk Karabulut, Gamze; Fazil, Korhan; Karaagac Gunaydin, Zehra; Serefoglu Cabuk, Kubra; Onmez, Funda Ebru; Taskapili, Muhittin
To evaluate surgical outcomes of Müller muscle conjunctival resection surgery for reoperation of residual ptosis after external levator advancement in patients with aponeurotic ptosis.
A total of 23 eyes of 23 patients who had undergone Müller muscle conjunctival resection for residual ptosis between January 2016 and July 2018 were reviewed retrospectively. Margin reflex distance (MRD), interlid crease, and show distance measurements were performed with a ruler in millimeters during the office examination, and the photographs of patients were taken before the procedure and on the 10th day, at the first, third, and sixth months after the procedure. The successful outcome was described as MRD1 between 3 and 5 mm, interlid MRD1 difference ≤1 mm, interlid crease difference ≤2 mm, interlid show difference ≤2 mm, and the presence of symmetrical lid contour.
The mean increases in MRD1 were statistically significant at the first, third, and sixth months postoperatively when compared with preoperative values both before external levator advancement and before Müller muscle conjunctival resection (p = 0.000). There was statistically significant decrease in interlid MRD1 difference, interlid crease difference, and interlid show difference relative to preoperative values. Interlid crease and show difference within the range of successful outcome criteria were achieved in all patients. However, interlid MRD1 difference exceeded 1 mm in only 1 patient who had overcorrection.
In patients who have residual ptosis without contour abnormality following external levator advancement, and positive response to phenylephrine testing, Müller muscle conjunctival resection is an effective approach.
Adam R. Sweeney, Christopher R. Dermarkarian, Katherine J. Williams, Richard C. Allen, Michael T. Yen
To compare outcomes between Müller muscle conjunctival resection (MMCR) ptosis repair and external levator resection (ELR) in patients with severe involutional blepharoptosis.
Retrospective, interventional, comparative case series.
A retrospective review was performed of patients who underwent ptosis repair between 2012 and 2019. Inclusion criteria were patients who underwent MMCR or ELR ptosis repair, patients with complete documentation of preoperative eyelid measurements, and patients with documentation of postoperative outcome. The main outcome measure was surgical failure, defined as patient-reported or physician-reported dissatisfaction with postoperative eyelid height or postoperative upper margin reflex distance (MRD1) of less than 2 mm. Severe ptosis was described as an MRD1 of 0 or worse. Outcome analysis was also performed after stratification for concomitant blepharoplasty performed at the time of ptosis repair.
A total of 231 patients (372 eyelids) met the study criteria, of which 142 eyelids had severe ptosis. Comparing outcomes of MMCR vs ELR in patients with severe ptosis, there was a statistically significant higher rate of success after MMCR ( P = .0143). The rate of ptosis repair success in eyelids that underwent MMCR was 97.2% and 90.9% in patients with severe ptosis and mild/moderate ptosis, respectively ( P = .42). In eyelids that underwent ELR, the rate of ptosis repair success was 77.4% and 85% in eyelids with severe ptosis and mild/moderate ptosis, respectively ( P = .15). Concomitant blepharoplasty did not affect ptosis repair outcomes in any group.
MMCR ptosis repair is an effective approach in treating patients with severe ptosis, and it may offer superior outcomes to ELR. In patients with good responses to phenylephrine, MMCR may offer an efficient and highly efficacious surgery regardless of presenting MRD1.
Gavin W. Roddy, Bingying Zhao, Feng Wang, Chengbo Fang, Sunil S. Khanna, Jasmina Bajric & Cheryl L. Khanna
To determine the degree and rate of ptosis in patients undergoing glaucoma and cataract surgery.
Patients undergoing cataract extraction (CE), trabeculectomy, or glaucoma drainage device (GDD) placement, or a combination, were consecutively enrolled by a sole surgeon. Eyelid measurements, including margin reflex distance 1 (MRD1) and levator function, were obtained preoperatively and at 1 and 3 months postoperatively. Primary outcome measures were the change in MRD1 pre- vs postoperatively; percentage of patients with ptosis (defined as MRD1 < 2 mm pre- vs postoperatively). Secondary measures were the absolute change in MRD1 between groups, decrease in MRD1 of ≥ 2 mm, and change in levator function.
In total, 104 eyes of 73 patients underwent CE, trabeculectomy, or GDD placement and completed at least 1-month follow-up; 93 eyes of 65 patients completed 3-month follow-up. MRD1 decreased significantly in trabeculectomy and GDD groups at 1 and 3 months postoperatively, while it did not change in the CE group. The GDD group had a significant increase in percentage of patients with ptosis at 3 months postoperatively.
Patients who underwent glaucoma surgery, especially those who underwent GDD placement, were more likely to have postoperative ptosis than patients undergoing CE alone. High ptosis rates in patients undergoing glaucoma surgery may warrant preoperative counseling and post-operative referral to oculoplastic surgeons.
Hauck, Matthew J.; Steele, Eric A.; Perry, C. Blake
To evaluate the ability of preoperative phenylephrine testing to predict postoperative upper eyelid tarsal platform show in patients undergoing Müller muscle–conjunctival resection (MMCR) ptosis repair without concurrent blepharoplasty.
A retrospective chart review was performed on 52 eyelids of patients who underwent MMCR without external skin incision. Photographs were reviewed to objectively and subjectively compare the results of phenylephrine testing to postoperative appearance. Only patients who underwent successful MMCR were included in the study. The authors defined successful MMCR as having a resulting marginal reflex distance within 1 mm of that predicted by phenylephrine testing. For objective analysis, the tarsal platform show was measured using computer software. For subjective analysis, 2 experienced examiners were asked to grade the correlation in appearance on a scale of 1–5 (1 being poor correlation and 5 being excellent correlation).
The mean tarsal platform show in the phenylephrine test photographs and the postoperative photographs was 3.8 and 3.63 mm, respectively (mean = 0.17; standard deviation = 0.71). The difference between the means was not statistically significant (p > 0.05). The mean difference in tarsal platform show between phenylephrine testing and postoperative was 0.17 mm (standard deviation = 0.71). The difference was not statistically significant (t = 0.09; p > 0.05; 2 tailed). The mean subjective correlation score comparing phenylephrine testing photographs to postoperative photographs was 4.4 out of possible 5.
Phenylephrine testing exhibits good predictability with regard to eyelid appearance after successful MMCR without external skin incision and, therefore, may assist the surgeon when trying to decide if blepharoplasty or eyelid crease formation is necessary at the time of MMCR.
Josiah To, MASc; Marian Macsai, MD; Paul O. Phelps, MD
A 76-year-old white woman with a history of left corneal stem-cell deficiency and cataract presented for a second opinion of recurrent left upper eyelid blepharedema, ptosis, erythema, photophobia, mucopurulent discharge, and a feeling she described as a “knife in my left eye” over the past 4 years (Figure 1). Previous treatment included topical steroids, antibiotics, and serum tears, with temporary relief. However, she experienced recurrences of symptoms after therapy discontinuation. Additional treatment included weekly bandage contact lenses for many months, which made the left eye pain tolerable. A dacryocystogram of the left lacrimal system indicated partial dacryostenosis, but compression of the canaliculi and lacrimal sac did not exacerbate discharge. A prior computed tomography scan of the orbits and sinuses showed no abnormalities. Her visual acuity was 20/30 OD and 20/100 OS. Deep superior conjunctival fornices were noted in both eyes (Figure 1), and eversion of the left upper eyelid revealed a pseudomembrane of the tarsal conjunctiva. Cultures of the copious discharge demonstrated many gram-negative Serratia marcescens. She subsequently started treatment with topical prednisolone acetate, moxifloxacin, and systemic azithromycin.
Victoria Marqués-Fernández, Maria Garcia-Zamora, Maria Calabuig-Goena, Cecilia Diez-Montero, Silvana A. Schellini, Rajiv Khandekar & Alicia Galindo-Ferreiro
Purpose: To objectively measure the upper eyelid position following phacoemulsification cataract surgery and to identify the determinants of postoperative transient ptosis.
Methods: This is a single arm prospective study of patients who underwent cataract surgery from January to May 2017 at a tertiary Eye Hospital in Spain. Data comprised of: the type of anesthesia, the duration that the speculum remained in place and the total surgical time (duration of the procedure). The total surgical time was defined as, the time from the beginning of the paracentesis to the closure of the wounds (incision time). Digital photographs were obtained of: the face with the eye in primary gaze, looking inferiorly and superiorly, preoperatively, and 1, 30, 90 and 180 days postoperatively. Measurements for eyelid crease, levator function, and marginal reflex distance 1 (MRD1) were performed using ImageJ. Statistical analysis was performed of the difference between the preoperative and postoperative measurements.
Results: The study consisted of 112 patients. The median lid crease was 9.0 mm [IQR (interquartile range) 7.5; 10.0] both preoperatively and at 180 days postoperatively (IQR 8.0; 10.8). No statistical difference was determined in the lid crease measurements between these two times (P = .17). The median levator function differed significantly preoperatively, at day 1 and 30, 60 and 180 days postoperatively (P < .01). MRD1 decreased significantly from a median of 3.01 mm preoperatively to 2.7 mm at 30 days postoperatively (P = .05) but was similar at preoperative and after 180 days (P = .7). The correlation of MRD1 to the duration of the speculum in place (P = .2) and the incision time (P = .57) was not significant.
Conclusions: Ptosis, following phacoemulsification cataract surgery, is mild and transient, occurring only in the early postoperative period.
Michael G. Sun, Duangmontree Rojdamrongratana, Mark I. Rosenblatt, Vinay K. Aakalu & Charles Q. Yu
Blepharoptosis or ptosis is a common and potentially debilitating clinical problem. Long-term surgical treatment for ptosis caused by progressive myopathies can be challenging due to potential recurrence and complications associated with facial muscle weakness. When surgical treatment is no longer effective, an eyelid crutch can be used as an alternative intervention. This report demonstrates how 3D printing was used to rapidly design, prototype, and manufacture new custom-fit eyelid crutches at a low cost.
Abhidnya Surve, M. C. Sharma, Neelam Pushker, M. S. Bajaj, Rachna Meel, Seema Kashyap
To study microscopic and ultrastructural changes of levator palpebrae superioris (LPS) muscle in congenital ptosis.
In this prospective observational study, LPS muscle was studied in 77 eyelids with congenital ptosis; 35—simple congenital ptosis (SCP), 12—Marcus Gunn jaw winking phenomenon (MGJWP), and 30—blepharophimosis epicanthus inversus syndrome (BPES). Light microscopy, enzyme histochemistry, immunohistochemistry and electron microscopy were performed, and results were analyzed.
Muscle fibers were detected in 83.33% of MGJWP, 22.86% of SCP and 16.67% of BPES eyelids. Fibers were detected significantly more in individuals with moderate ptosis, LPS action > 4 mm, present eyelid crease and eyelid fold. Severe endomysial and perimysial fibrosis was seen significantly more in individuals with MGJWP. Fat infiltration and nuclei internalization were seen in all three groups. The absence of degenerating or regenerating fibers and inflammatory cells, normal staining pattern on immunohistochemistry and absence of accumulation of any abnormal substance were found in all three groups. Abnormal mitochondrial staining pattern was seen occasionally in three groups. On electron microscopy, muscle was detected in 1 SCP eyelid and 8 MGJWP eyelids out of which 4 had myofibrillary disruption. All other eyelids where muscle fibers were not detected had only fibrocollagenous tissue.
Fibrocollagenous tissue predominated in all the cases, and muscle fibers detected correlated inversely with the severity of ptosis. The absence of degenerating, regenerating fibers and inflammatory cells supported the theory of dysgenesis of muscle. However, internalization of nucleus seen in all the subtypes is a feature favoring dystrophy.
Bautista, Sana Ali; Wladis, Edward J.; Schultze, Robert L.
Purpose: Müller’s muscle-conjunctival resection (MMCR) is a highly effective technique to correct upper eyelid ptosis. However, several authorities have raised concerns about the possibility of postoperative ocular surface dryness. This study was performed to assess the impact of MMCR on clinically meaningful parameters of the ocular surface.
Methods: In adult patients, tear break-up time, lipid layer thickness, and osmolarity were measured via direct observation, interferometry, and impedance measurements before surgery and 3 months after surgery in patients who underwent MMCR. Statistical analysis was performed via a dedicated software package.
Results: Fifteen eyes of 14 patients were included in the study. Mean pre- and postoperative tear break-up times were 12.71 ± 2.20 and 12.43 ± 2.41 seconds, respectively (p = 0.1648). Preoperatively, the mean lipid layer thickness measurement was 91.00 ± 7.02 nm, whereas the mean postoperative value was 88.86 ± 21.36 nm (p = 0.6613). The mean preoperative tear osmolarity measured 291.4 ± 8.86 mOsm/l, and the mean postoperative measurement was 289.86 ± 9.74 mOsm/l (p = 0.2652).
Conclusions: MMCR does not appear to change clinically meaningful ocular surface disease parameters, and postoperative dryness did not result from this procedure. In appropriately selected patients, MMCR can be safely performed without increased concerns regarding postoperative dry eye disease.