A retrospective chart review of 251 new frontalis slings suggests that surgical closure technique significantly affects the rates of postoperative infection and exposure. The role of prophylactic systemic antibiotics in reducing infection and exposure is less clear.
Treatment of Congenital Ptosis in Infants With Associated Amblyopia Using a Frontalis Muscle Flap Eyelid Reanimation Technique
Eton, Emily A.; Carniciu, Anaïs L.; Prabhu, Shreya S.; Wang, Grace M.; Kahana, AlonRead More
To determine the efficacy of a frontalis muscle flap eyelid reanimation technique for correction of severe congenital ptosis and associated amblyopia in infants.
The authors performed a retrospective chart review of patients 12 months of age or younger with unilateral or bilateral congenital ptosis and associated amblyopia or deemed at high risk for amblyopia due to visual deprivation. Following ptosis repair via a frontalis muscle flap technique, primary outcomes of postoperative eyelid position and amblyopia reversal were assessed.
Seventeen eyes of 12 participants were included for study. Seven of these patients had simple congenital ptosis, and the remainder had ptosis as part of a syndrome. Nine were diagnosed with amblyopia preoperatively, and the remaining 3 were too young for acuity testing but had occlusion of the visual axis by the ptotic eyelid in primary gaze. Postoperatively, the mean margin-to-reflex distance 1 was 2.4 mm (range: 0.0–4.0), and 9 patients (75%) demonstrated no evidence of amblyopia. Only 2 patients had eyelid asymmetry greater than 2 mm, which in both cases was due to lack of frontalis activation by the patient secondary to ongoing visual impairment. The most common complication was lagophthalmos in 6 eyes (35.3%), with no significant associated surface keratopathy.
The frontalis muscle flap technique may offer a new and effective approach to treating infants with severe congenital ptosis causing poor eyelid excursion and associated amblyopia while avoiding use of an implant.
Single-triangle versus Fox pentagon frontalis suspension for unilateral severe congenital ptosis correction
Nora Mahmoud, Mohammed,Mahmoud, Ahmed Kamal, Mohammed Ahmed, Abdelhafez,Mostafa, Mohammed DiabRead More
To compare the functional and cosmetic outcomes of two different frontalis sling techniques for correction of severe unilateral congenital ptosis: single triangle and Fox pentagon techniques using expanded polytetrafluoroethylene (ePTFE) suture.
This randomized controlled trial included 60 eyes of 60 patients with severe unilateral simple congenital ptosis and poor levator function (≤4 mm). Participants were randomly assigned for either single triangle or Fox pentagon frontalis suspension using ePTFE suture. Functional outcome measures were margin reflex distance (MRD1), palpebral fissure height (VFH), and lagophthalmos. Cosmetic outcome parameters (lid contour, lid crease, and height symmetry) were graded as 3 (excellent), 2 (good), or 1 (poor), with a minimum of 18 months’ follow-up.
At final follow-up, there was a significant improvement in the MRD1 and VFH in both groups, with no statistical difference ( P = 0.9). Both groups showed comparative cosmetic results regarding lid height symmetry, crease, and contour. The patients in the single-triangle group showed more rapid recovery of postoperative edema and lagopthalmos with less visible forehead scarring. There were no serious ePTFE sling–related complications.
In our study cohort, the single-triangle and Fox pentagon frontalis suspension techniques had similar outcomes with respect to MRD1 and VFH and comparable cosmetic results. However, the single-triangle technique avoids two forehead incisions and was associated with less postoperative edema, lagophthalmos, and scarring.
Prevalence and risk factors of childhood blepharoptosis in Koreans: the Korea National Health and Nutrition Examination Survey
Purpose: Childhood blepharoptosis may cause cosmetic and functional problems in children, but there is a paucity of studies about its epidemiology. This study aimed to investigate the prevalence of childhood blepharoptosis and associated risk factors in a representative Korean population. Methods: This cross-sectional nation-wide study analysed the data set acquired from the Korea National Health and Nutrition Examination Survey 2008–2012. A total of 8218 children aged 3–18 years were included. The prevalence of childhood blepharoptosis, defined as a margin reflex distance (MRD) of < 2 mm in either eye, was estimated, and the risk factors were identified using multivariate logistic regression analysis. Results: The mean age of participants was 11.3 ± 0.1 years, and 52.8 ± 0.6% were boys. The overall prevalence of childhood blepharoptosis in Korea was 8.0% (95% CI, 6.9–9.1%). Boys exhibited a higher prevalence of blepharoptosis than girls at most of ages. Levator function increased with age in the normal general population. The proportion of subjects exhibiting MRD1 ≥ 4.0 mm also increased significantly with age (p < 0.001). Male gender, higher body mass index, and urban residency were significantly associated with childhood blepharoptosis. Conclusions: The prevalence of childhood blepharoptosis is higher in urban obese boys. The increase of levator function with age should be considered in evaluations of childhood ptosis.
Childhood blepharoptosis may cause cosmetic and functional problems in children, but there is a paucity of studies about its epidemiology. This study aimed to investigate the prevalence of childhood blepharoptosis and associated risk factors in a representative Korean population.
This cross-sectional nation-wide study analysed the data set acquired from the Korea National Health and Nutrition Examination Survey 2008–2012. A total of 8218 children aged 3–18 years were included. The prevalence of childhood blepharoptosis, defined as a margin reflex distance (MRD) of < 2 mm in either eye, was estimated, and the risk factors were identified using multivariate logistic regression analysis.
The mean age of participants was 11.3 ± 0.1 years, and 52.8 ± 0.6% were boys. The overall prevalence of childhood blepharoptosis in Korea was 8.0% (95% CI, 6.9–9.1%). Boys exhibited a higher prevalence of blepharoptosis than girls at most of ages. Levator function increased with age in the normal general population. The proportion of subjects exhibiting MRD1 ≥ 4.0 mm also increased significantly with age (p < 0.001). Male gender, higher body mass index, and urban residency were significantly associated with childhood blepharoptosis.
The prevalence of childhood blepharoptosis is higher in urban obese boys. The increase of levator function with age should be considered in evaluations of childhood ptosis.
Re: “Müller’s Muscle-conjunctival Resection Combined With Tarsectomy for Treatment of Congenital Ptosis”
Ullrich, Katja; Malhotra, RamanRead More
Gazit, Inbal; Gildener-Leapman, Juliana; Or, Lior; Burkat, Cat N.; Pras, Eran; Hartstein, Morris E.
Suresh Sagili, Jerome HaRead More
We describe a novel modification of levator advancement for congenital upper eyelid ptosis, in a case series. Written informed consent was obtained from all patients/parents. Local institutional review board approval was granted.
All procedures were performed under general anaesthesia. A cornea protector is recommended to protect the globe. The upper eyelid is everted and local anaesthetic (bupivacaine 0.25% with 1:200 000 adrenaline) is injected subconjunctivally (0.5 mL), superior to the tarsus. Local anaesthetic is also injected subcutaneously (1 mL) along the pretarsal region. An incision is placed in the upper eyelid skin crease, and dissection through the orbicularis is aimed toward the superior tarsus. The levator aponeurosis is grasps and dissection is then continued between the posterior levator aponeurosis and Müller’s muscle/conjunctival tissue, exposing the posterior surface of levator aponeurosis, commonly visible as a “white line.” Blunt dissection is then continued in this tissue plane to expose the posterior surface of levator. A single-armed 5-0 Vicryl suture (1/4 circle, spatulated needle) is placed partial thickness through the posterior surface of levator and advanced toward the previously exposed anterior tarsus (Fig. 1). Two sutures on a temporary knot are placed 2 mm on either side of the midpupillary line. The upper eyelid margin is left at the level of the superior limbus. The eyelid height can be adjusted by placing the sutures lower or higher on the posterior surface of the levator muscle if the upper eyelid appears overcorrected or undercorrected, respectively. The sutures are then permanently tied. The skin incision is closed with dissolvable sutures.
Fifteen eyelids of 14 patients (8 males, 6 females) were included in this study. Median age was 17 years (range 7–42 years). Thirteen patients had unilateral congenital ptosis and one was bilateral. None had jaw-wink synkinesis and recurrent ptosis.
The mean postoperative follow-up was 14 months (range 2–48 months). Mean levator function was 8 mm (range 6–10 mm). Mean preoperative margin reflex distance (MRD1) was 0.5 mm (range 0–1 mm), and the mean postoperative MRD1 was 3.2 mm (range 2–4 mm).
Postoperative results are shown (Fig. 2). There were 2 undercorrections and no overcorrections. All patients had mild exposure keratopathy, which improved with conservative management.
Anterior approach levatorpexy surgical technique is similar to the anterior approach white-line advancement, described by Sagili, for correction of adult aponeurotic upper eyelid ptosis.
However, in levatorpexy the dissection is continued upward beyond the levator aponeurosis (white-line) to expose and advance the levator muscle. We perform anterior levatorpexy in patients with a levator function of 6 mm or better.
Posterior approach levatorpexy described by Al-Abbadi et al is a similar technique, where the posterior surface of the levator is advanced through a conjunctival incision. Posterior approach upper eyelid ptosis correction techniques are believed to provide better cosmetic results because these techniques do not disrupt the orbital septum and pre-aponeurotic fat pad.
Anterior approach levatorpexy retains this advantage of keeping the orbital septum and pre-aponeurotic fat pad intact and avoids a conjunctival incision or excision of any tissue.
Effect of congenital blepharoptosis on corneal biomechanical properties and changes after ptosis surgery
Xingyi Li, Chang Liu, Zhen Mao, Xuanwei Liang, Zuohong Li, Xuehua Liu, Ruowen Gong & Danping HuangRead More
We studied the difference in the corneal biomechanical parameters of ptotic and fellow eyes in patients with congenital blepharoptosis. The correlations between corneal biomechanical parameters and demographic or ocular parameters, and the changes after surgery were also researched.
The corneal biomechanical parameters were measured by Corvis ST tonometry. The central corneal thickness (CCT), axial length (AL) and keratometry measurements were performed with LenStar LS900, and intraocular pressure (IOP) by non-contact applanation tonometry. The parameters were evaluated for the effect of ptosis and the relationship of corneal biomechanical parameters. These examinations were repeated 6 months after blepharoptosis surgery.
Twenty-nine patients were enroled. The Corvis ST parameters (Deformation amplitude [DA], A1 times, and A1 velocity), CCT, IOP with NCT, IOP with corrected, differed significantly between ptotic and fellow eyes. CCT was significantly positively correlated with Length A1 and IOP with Corvis, and negatively correlated with IOP corrected by Corvis of the ptotic eyes. The same tendency was found in the fellow eyes. Six months after the ptosis surgery, the differences in corneal biomechanics parameters between ptotic eyes and fellow eyes were not significantly changed.
Congenital blepharoptosis causes significant corneal biomechanical changes measured by Corvis ST. The ptotic eyes had thicker and less deformable corneas. The differences in corneal biomechanics between ptotic eyes and fellow eyes were mostly related to CCT changes. Six months after surgery, these differences in corneal biomechanics did not change significantly.
Francesco M. Quaranta‐Leoni Roberto Secondi Flavia Quaranta‐Leoni Stefano NardoniRead More
To evaluate the different degree of muscle atrophy in specimens of levator muscle of patients operated on for unilateral congenital ptosis, as related to the age of the patient.
Histological analysis of the specimen of the levator muscle of 29 patients who underwent a unilateral levator muscle resection under the care of one surgeon was performed. The study population was divided into two different groups according to the timing of surgery: group 1 included 15 children operated on at 2 to 4 years, and group 2 included 14 children operated on at 4.1 to 11 years.
Levator muscle of 12 patients of group 1 showed mild degree of muscle atrophy, with striated muscle fibres separated by thin fibrous septa incorporating groups of cells with peripheral nuclei and non‐hyalinized cytoplasm (Masson’s trichrome stain). In eight cases of group 2, levator muscle showed instead severe atrophy, with discontinuous striated muscle fibres separated by thick fibrous septa including cells with centralization of nuclei, hyalinization of cytoplasm (Masson’s trichrome stain) and fatty infiltration.
Myofibres found in specimens of levator muscle following levator resection for congenital ptosis show characteristics of a degenerative process. This study seems to demonstrate that atrophy in the levator muscle appears to be related to the age of the patient at surgery, as atrophy tends to be more evident in older children with congenital ptosis.
Ozlem Ural, MD; Mehmet C. Mocan, MD; Ugur Erdener, MDRead More
To evaluate the overall frequency of visual function loss in pediatric patients with congenital blepharoptosis.
This retrospective study was conducted in a tertiary center. The clinical records of patients younger than 18 years who were diagnosed as having congenital blephroptosis, underwent surgery, and had at least 1 year of postoperative follow-up were evaluated. Visual acuity results, presence of structural eye abnormalities, presence and type of amblyopia and strabismus, and refractive errors were recorded. The Mann–Whitney U test, chi-square test, and stepwise regression analysis were used for statistical analyses.
The mean final visual acuity was 0.11 ± 0.23 logarithm of the minimum angle of resolution (logMAR) (range: 0.0 to 1.0 logMAR) at the final follow-up visit for 143 eyes of 123 patients (65 male and 58 female). In this cohort, 30 patients (24.4%) had amblyopia and 5 patients (4.1%) had visual loss related to structural eye pathology, amounting to a total of 35 patients (28.5%) with visual function loss. The mean final visual acuities of patients without amblyopia, patients with amblyopia, and patients with organic eye disorders were 0.01 ± 0.03, 0.29 ± 0.28, and 0.55 ± 0.42 logMAR, respectively. Severe blepharoptosis (≥ 4 mm) was present in 25 patients (83.3%) with amblyopia. Deprivational amblyopia was detected in 25 of 36 eyes (69.4%) with amblyopia. Independent risk factors associated with final visual acuity were presence of amblyopia at presentation (correlation coefficient [ß] ± standard error [SE] = −0.29 ± 0.04; P < .001), anisometropia (ß ± SE = −0.27 ± 0.06; P < .001), and ptosis severity (ß ± SE = −0.09 ± 0.04; P = .012). Visual impairment (visual acuity < 20/40) persisted in 11.9% of eyes at the final follow-up.
Visual function loss was present in one-third of pediatric patients with congenital blepharoptosis. Both amblyopia and structural eye disorders contribute to visual impairment in this patient population. Structural eye pathology contributes independently to 4.1% of visual loss in this clinical setting.
Al-Faky, Yasser H.; Abu El-Eneen, Mohamed A.; Selim, Khaled M.; Ali, Hassan A.Read More
To assess the effect of releasing the central attachment between the Whitnall’s ligament (WL) and the levator palpebrae superioris muscle on the postoperative levator function (LF), eyelid lag, and degree of lagophthalmos.
This retrospective case-control study included patients with moderate and severe simple congenital ptosis who underwent skin approach levator aponeurosis resection (LR) as a primary procedure with a minimum of 6-month follow up. Patients were divided into 2 groups; the first group underwent LR without WL release (control group) while the second group underwent LR with WL release. Preoperative demographics and clinical data were reviewed. Postoperative LF, eyelid lag, and degree of lagophthalmos as well as surgical outcomes were compared and analyzed in both groups.
A total of 81 patients (88 eyelids) were included in this study. There were 50 males (61.7%). The mean age was ±SD 12.0 ± 9.5 years. The first group included 43 eyelids while the second had 45 eyelids. There was no statistical difference in demographics and preoperative data between both groups. The postoperative LF was higher in the second group (10.7 ± 2.1 mm) with less consecutive eyelid lag compared with the control group (7.8 ± 1.9 mm) (p < 0.001). The control group had acquired more postoperative lagophthalmos compared with the second group (p < 0.001). Complete surgical success was achieved in 82.2% in the second group compared with 60.5% in the control group (p = 0.024).
Releasing the central attachment between WL and levator palpebrae superioris muscle has achieved an improvement in LF with minimal postoperative eyelid lag, lagophthalmos, and corneal complications.
Releasing the central attachment between levator palpebrae superioris muscle and Whitnall’s ligament during levator aponeurosis resection allows better levator excursion and minimizes postoperative lagophthalmos, eyelid lag, and corneal complications.