Phillip M. Radke, Tal J. Rubinstein, Daniel J. Repp & Bryan S. Sires
Purpose: To directly compare an algorithmic external levator resection technique with the choice of intraoperative adjustment to the same technique without intraoperative adjustments.
Methods: A sequential controlled prospective comparative cohort study. Two cohorts were compared: a historical control adjustment, and an experimental non-adjustment group. Fourteen patients, 25 eyelids, were in the historical cohort; and 15 patients, 23 eyelids, were in the non-adjustment cohort. Primary acquired ptosis patients who met inclusion criteria were considered. All patients underwent a standardized external levator resection technique. Intraoperative adjustments were performed only in the historical cohort. Age, follow-up time, surgical time, and marginal reflex distance 1 (MRD1) were collected. Statistical analysis was performed using the Mann–Whitney U test. Statistical significance was p < 0.05. Primary and secondary outcome measures were postoperative MRD1 minus goal MRD1, and surgical time, respectively.
Results: Twenty-five historical eyelids were compared with 23 non-adjusted eyelids. The average patient age was 68.4 years (range 19–84) and 59.3 years (range 24–83) for the adjusted and non-adjusted groups. Six-month postoperative (postoperative minus goal) MRD1 was −0.1 mm (95% CI −0.3–0.1) and −0.2 mm (95% −0.5–0.0) (p = 0.33), and surgical time was 13.8 min (95% CI 12.6–15.1) and 9.5 min (95% CI 9.0–10.1) (p < 0.001) for the adjusted and non-adjusted cohort, respectively.
Conclusions: The external levator resection, utilizing a standardized algorithm approach, is an efficacious technique for involutional eyelid ptosis. With sound technique, this method can be performed without the need for intraoperative adjustment, thereby saving operative time and achieving similar results.
Namita Kumari, Sweety Girijashankar Tiple, Sima Das & Nitish Arora
Tatiana Sofia Monteiro Queirós MD Hae‐Ryung Won‐Kim MD Andrea Sales‐Sanz MD Marco Sales‐Sanz MD. PhD.
To investigate the effect of Phenylephrine test on the upper eyelid crease position.
Material and Methods
This study follows a prospective and analytical design and included patients with unilateral acquired involutional ptosis recruited between January 2015 and January 2018. In the Phenylephrine test, 1 drop of Phenylephrine 10% was instilled on the inferior fornix of the ptotic eye and the eyelid crease position was evaluated 10 min after.
A total of 60 patients were included in the final sample. The mean Margin‐to‐reflex distance 1 (MRD1) of the ptotic eye was 2.1 ± 1.0 and 3.8 ± 0.6 mm before and 10 min after the instillation of Phenylephrine, respectively. The difference between the means was statistically significant (p < 0.001). Ninety‐five per cent of the eyes had a positive Phenylephrine test result. Of this, 100% showed a decrease in the height of eyelid crease after the drop. There was a statistically significant decrease in the height of eyelid crease from 10.3 ± 2.5 to 7.8 ± 2.0 mm (p < 0.001).
Phenylephrine test not only affects the eyelid position but also the eyelid crease height. We show a significative decrease in eyelid crease height to a symmetrical level with the contralateral lid in all patients that had a positive Phenylephrine test result. This effect is probably due to a posterior lamella shortening secondary to Müller’s muscle contraction and suggests that the eyelid crease is not only determined by the projections of levator aponeurosis, but also by the entire force vector of the upper eyelid retractors.
Lam, Aimee N.; Thayer, Jessica N.; Rahman, Effie Z.; Martinez, Andre N.; Fry, Constance L.
To investigate the prevalence and frequency of patients with blepharoptosis who take anticholesterol therapies. To our knowledge, this is the first large single-center series to evaluate this association.
A retrospective chart review of adult patients presenting with ptosis on concomitant anticholesterol medications.
Two hundred ninety-three adult patients with ptosis taking anticholesterol therapy were identified from October 2011 to October 2016. Forty-seven patients (16.0%) reported muscle weakness. Laboratory markers including creatine kinase (CK) and myoglobin levels were obtained. Of the 47 patients, 13 patients (4.4%) were identified to have ptosis and laboratory confirmed anticholesterol therapy-induced myopathy. Two additional patients with statin-induced myositis and rhabdomyolysis were identified from the period 2008–2011. All patients had measurably elevated CK and/or myoglobin levels. All patients experienced improvement in ptosis or systemic symptoms after discontinuation or changing medications. Nine patients (60%) demonstrated statistically significant improvement in the ptosis.
Many patients with involutional ptosis also have both cardiovascular disease and hyperlipidemia and thus take cholesterol-lowering medication. Our study demonstrates a World Health Organization-defined probable association between ptosis and anticholesterol-induced myopathy. The frequency of anticholesterol-induced myopathy in adult ptosis was 4.4%, which is substantially higher than previously predicted. Anticholesterol-induced myositis can cause a reversible ptosis, and thus, a thorough evaluation of adult patients presenting with involutional ptosis includes inquiry into the use of anticholesterol drugs and associated muscle weakness.
Anticholesterol medication may induce or exacerbate myogenic ptosis in some individuals.
Lawrence J. Oh, Eugene Wong, Sol Bae & Angelo Tsirbas
Traditionally, posterior eyelid surgical approaches such as Müller’s muscle-conjunctival resection (MMCR) have been utilised with great success for mild cases of ptosis, with external levator approaches having been used for more severe cases of ptosis. We present a new technique which we label closed posterior levator advancement (CPLA) for the correction of all grades of ptosis. This article is a retrospective cohort study reviewing patients with mild, moderate, and severe ptosis over a 6-year period, treated by a single surgeon using CPLA. Minimum follow-up was 3 months. Patients with good levator function (levator palpebrae superioris (LPS) function >10 mm) without concomitant procedures were subdivided based on margin-to-reflex-distance-1 (MRD1) into mild-to-moderate ptosis (MRD1 > 1.5 mm) and severe ptosis (MRD1 ≤ 1.5 mm) cohorts. The outcome measures were preoperative and postoperative MRD1, lid contour, intereye symmetry, complications, and revision rates. 393 eyes of 313 patients were identified. 91 eyes in the mild-to-moderate cohort had a preoperative MRD1 of 2.38 mm, and 302 eyes in the severe cohort had a preoperative MRD1 of 0.27 mm. Postoperatively, MRD1 was 3.86 mm and 3.49 mm, respectively. There were no significant complications in both cohorts, and revision rates were 3.3% (3 of 91 eyes) in the mild-to-moderate and 2% (6 of 302 eyes) in the severe cohorts. Upper-eyelid contour was satisfactory in 98.2% of eyes, and 97.5% intereye symmetry within 1 mm was observed. Our results show an effective correction of all ptosis grades with satisfactory cosmetic outcomes and low complication and revision rates.
Daisuke Sato, Hirotaka Suga, Mine Ozaki, Keigo Narita, Tomohiro Shiraishi, Kiyonori Harii, Akihiko Takushima
Levator aponeurosis surgery, in which the levator is reattached or advanced to the tarsus, is a widely used technique for the treatment of involutional blepharoptosis. Although this surgical treatment can achieve good results both functionally and aesthetically, few studies have analyzed patient satisfaction after this surgical treatment. In the present study, we investigated the patient satisfaction after levator aponeurosis surgery by asking patients to complete a postal questionnaire, and we analyzed the factors affecting their satisfaction/dissatisfaction.
Kenichi Kokuboa, Nobutada Katorib, Kengo Hayashic, Jun Sugawarad, Seiko Koue, Akiko Fujiif, Shoko Hagaa, Jiro Maegawaf
Eyebrow descent commonly occurs after ptosis repair or blepharoplasty surgery. The procedures used to correct acquired blepharoptosis are primarily classified into four groups. These procedures target the levator aponeurosis, Müller’s muscle, both the aponeurosis and Müller’s muscle, or the frontalis muscle. In this study, we used a new technique called external Müller’s muscle tucking (EMMT) on 51 patients (94 eyelids), which targets the Müller’s muscle for involutional blepharoptosis. The patients were assessed by comparative analysis using pre- and post-operative digital photographs. The distances between the medial canthi, in addition to the eyebrow heights at the medial canthus, pupil and lateral canthus, were measured on a computer screen. Eyebrows descended after surgery at the medial canthus in 53 eyelids (56.4%), at the center of the pupil in 55 eyelids (58.5%) and at the lateral canthus in 48 eyelids (51.1%). The mean distances of eyebrow descent in the 94 eyelids were 0.24, 0.51 and 0.32 mm at the medial, center and lateral positions, respectively. The mean preoperative margin reflex distance (MRD) was −0.05 mm, the mean postoperative MRD was 3.79 mm and the mean change in MRD was 3.83 mm. Preoperative MRD and change in MRD were weakly associated with changes in eyebrow position in 94 eyelids. In conclusion, these findings suggest that eyebrow drooping distance is related to the preoperative severity of ptosis.
Sinha, Kunal R.; Al Shaker, Sara; Yeganeh, Amir; Moreno, Tyler; Rootman, Daniel B.
Purpose: The purpose of this study is to explore mechanical and co-innervational factors involved in both voluntary and involuntary brow elevation among people affected by ptosis and dermatochalasis.
Methods: In this prospective cohort study of normal controls and eyelids with ptosis or dermatochalasis, marginal reflex distance (MRD1) and brow height were measured under the following conditions: neutral position, involuntary mechanical brow elevation, voluntary brow elevation, and maximal eyelid opening. The primary outcome measure was change in MRD1. Secondary outcome measures included brow height and coupling (mm brow height change per mm MRD1 change). Analysis of variance and t tests were performed for intra- and intercondition comparisons, respectively.
Results: Mechanical (involuntary) brow elevation significantly raised MRD1 in control eyelids and eyelids with dermatochalasis, but not in eyelids with ptosis. Voluntary brow elevation produced significantly greater brow height than maximal eyelid opening in controls and eyelids with dermatochalasis, but not in eyelids with ptosis. Maximal eyelid opening increased MRD1 greater than voluntary brow elevation significantly in control eyelids, but not in eyelids with dermatochalasis or ptosis. Coupling of the brow and eyelid margin during maximal eyelid opening was significantly greater in eyelids with ptosis relative to controls.
Conclusions: In eyelids with ptosis, mechanical brow elevation does not change eyelid position; however, voluntary brow elevation raises eyelid position to a similar position as maximal eyelid opening. These results argue against the contention that the brow is elevated to mechanically lift the eyelid in ptosis and instead suggest that the brow elevation is driven by efforts to raise the eyelid, possibly via co-innervation.
Jennifer Danesh MD, Shoaib Ugradar, Robert Goldberg & Daniel B Rootman
Both external levator resection (ELR) and Müller’s muscle-conjunctival resection (MMCR) are procedures well known to improve marginal reflex distance (MRD1) in patients with ptosis. This study aims to understand differential post-operative changes in eyelid contour for MMCR and ELR surgery.
In this cross-sectional cohort study, patients affected by involutional ptosis were randomized into two groups: those who underwent ELR or MMCR surgery. Pre-operative and late post-operative photographs were obtained. Digital analysis of the lid contour was performed by measuring the vertical distance from a line intersecting the center of the pupil to the eyelid margin at 10 positions at 2 mm intervals. Mean distance at each position was compared pre- and post-operatively between the groups.
The final sample included 60 eyes from 39 patients, 30 eyes per group. At each time point there was significant variation in height across the eyelid (p < 0.05). A significant (p < 0.05) group difference in vertical height was noted only at the 2 and 4 mm temporal positions in the post-operative analysis, with the ELR group being slightly higher. There were no significant differences in MRD1, pre- or post-operatively, between the ELR and MMCR groups.
Both ELR and MMCR are effective at elevating the eyelid in multiple positions across the length of the eyelid. Although they do not produce significantly different MRD1 results, ELR was associated with a greater eyelid height at the 2 and 4 mm temporal positions.
Phelps, Paul O.; Wladis, Edward J.; Meyer, Dale R.
Purpose: To investigate the association between upper eyelid position relative to the corneal light reflex (MRD1) and to delineate an association between eyelid height and involutional lower eyelid entropion.
Methods: Retrospective study of patients presenting for entropion repair to an academic ophthalmic plastic surgery service. A total of 111 patients were included in the study; 95 had unilateral involutional lower eyelid entropion, and 16 had bilateral lower eyelid entropion. Patients with a history of previous eyelid surgery, trauma, upper eyelid entropion, or cicatricial changes were excluded from the study.
Results: Of the 95 patients with unilateral involutional lower eyelid entropion, 45 (47.4%) had a lesser MRD1 on the side ipsilateral to the involutional lower eyelid entropion. In this unilateral group, the mean MRD1 (± standard deviation) on the ipsilateral to the involutional lower eyelid entropion was 2.9 (±1.2) mm, while the mean MRD1 on the contralateral side was 3.3 (±1.0) mm. This difference was 0.4 mm and was statistically significant (p < 0.0001). Most patients with unilateral involutional entropion demonstrated a right-sided involutional lower eyelid entropion (56 of 95; 58.9%), although this finding was not statistically significant (p = 0.083). The frequency of true blepharoptosis (MRD1 ≤ 2.0 mm) was 24 of 95 (25.3%) in the unilateral involutional entropion group and was even higher in the bilateral involutional lower eyelid entropion group, with 7 of 16 (43.8%) patients exhibiting bilateral blepharoptosis.
Conclusions: Patients presenting with involutional lower eyelid entropion tend to have a relatively reduced MRD1 on the ipsilateral (affected) side. When both lower eyelids are affected by involutional entropion, the reduced MRD1 tends to be more pronounced.
Barsegian, Arpine; Botwinick, Adam; Reddy, Harsha S.
Purpose: To characterize the phenylephrine test in ptotic patients to help clinicians perform the test more efficiently.
Methods: Adults with involutional ptosis (n = 24, 30 eyes) were assessed with digital photographs for response to topical 2.5% phenylephrine drop instillation. Patient characteristics (age, gender, iris color, dermatochalasis, brow ptosis, and baseline marginal reflex distance-1 [MRD-1] height) were recorded. From the photographs, change in (MRD-1), presence of conjunctival blanching, pupillary dilation, and Hering effect were recorded at specified time intervals, 1 minute to 1 hour after drop placement. Correlations between patient characteristics and measured outcomes were evaluated using analysis of variance, Pearson coefficient, or chi-square tests.
Results: The authors found that 73% of eyes had eyelid elevation with phenylephrine. Of these, 50% reached maximal eyelid elevation by 5 minutes, and 86% by 10 minutes after drop placement, but 14% did not reach maximal MRD-1 until 30 minutes. There is a negative correlation between the maximum MRD-1 and the baseline MRD-1 eyelid height (r = −0.5330, p < 0.01). There is no significant relationship between time to pupillary dilation with either time to max eyelid elevation or max eyelid elevation. No patient characteristic studied affected the likelihood of eyelid response to phenylephrine or presence of Hering effect.
Conclusions: Although most ptotic eyelids demonstrate a response to 2.5% phenylephrine within 10 minutes, there is a subset of patients that respond much later. More ptotic eyelids had greater eyelid elevation with phenylephrine. Pupillary dilation and conjunctival blanching are neither predictive of nor temporally associated with eyelid height elevation. The authors did not identify any patient factors (e.g., dermatochalasis, brow ptosis) that can predict the likelihood of response to phenylephrine.