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
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.
Al-Faky, Yasser H.; Abu El-Eneen, Mohamed A.; Selim, Khaled M.; Ali, Hassan A.
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.
Xiaobo Zhou, Ming Zhu, Lin Lv, Rui Jin, Jun Yang, Fei Liu
To establish a treatment protocol for severe blepharoptosis. This protocol helps to achieve improved accuracy and more stable correction outcome.
The levator muscle function was evaluated pre-operation. When the levator function was less than 1 mm, the frontalis suspension technique was performed; when the levator function was more than 1 mm, the techniques of levator resection, combined excision of the tarsus and levator, and tarsus–levator–CFS suspension were performed sequentially until a satisfactory correction result was achieved.
A total of 389 patients with severe ptosis (561 eyes) were included; 102 eyes received levator resection, 314 eyes received combined excision of the tarsus and levator, 53 eyes received tarsus–levator–CFS suspension, and 92 eyes received frontalis suspension. In total, a satisfactory correction result was achieved in 466 eyes, while 95 cases still presented with under-correction. The symmetry findings showed that 107 (27%) cases presented good symmetry, 203 (52%) cases presented moderate symmetry, and 79 (21%) showed poor symmetry.
This new treatment protocol overcomes the drawbacks of the traditional strategy by standardizing the correction procedure, leading to improved accuracy and more stable correction results.
Aaron Jamison, Ewan G. Kemp, Suzannah R. Drummond
To present our experience of paediatric blepharoptosis in a tertiary referral centre and evaluate the effectiveness of surgical intervention.
A retrospective cohort study of all children receiving surgical blepharoptosis correction between 1/1/10 and 29/2/16. Children with pre-operative levator function (LF) ≥ 7 mm received levator resection, those with LF ≤ 4 mm received brow suspension, and in those children with LF of 5–6 mm, either levator resection or brow suspension was chosen depending on the degree of frontalis recruitment.
Ninety-five children (109 eyes, 64 boys) underwent blepharoptosis surgery within the study period. Mean (range) age at surgery was 5.9 (1.2–12.5) years. Seventy-nine (83.2%) had simple levator maldevelopment. Fifteen children were excluded due to inadequate follow-up. Of the remaining 80 children, 41 (51.2%) underwent levator resection, 27 (33.8%) underwent fascia lata brow suspension, and twelve (15.0%) underwent mersilene mesh brow suspension. Margin reflex distance-1 was greatest at 6-week follow-up with a small “lid drop” by 6-month follow-up in both the levator resection (0.9 mm pre-operatively, 3.1 mm at 6-week follow-up, 2.6 mm at 6-month follow-up) and fascia lata brow suspension (0.3 mm, 2.5 mm, 2.2 mm) groups. No immediate complications, and only two serious post-operative complications, were noted. One case of residual blepharoptosis was re-operated (fascia lata brow suspension).
Surgical correction of paediatric blepharoptosis is safe and, after an observed lid drop between 6-week and 6-month follow-up (not seen in the mersilene mesh brow suspension group), effect appears to be maintained to 6 months and beyond. Readily accessible orthoptic assessment would help identify children at risk of amblyopia, both pre-operatively and post-operatively.
Sunah Kang, Ji Won Seo, Chan Joo Ahn, Bita Esmaeli, Ho-Seok Sa
Aim To calculate a regression formula for intraoperative lagophthalmos to determine the amount of correction in levator resection for mild to moderate congenital ptosis.
Methods This retrospective study included 38 eyelids from 28 consecutive children with congenital ptosis with levator function of 4 mm or better who showed satisfactory surgical outcomes defined as postoperative margin reflex distance-1 (MRD1) ≥3 mm in each eye and difference in MRD1 ≤1 mm between eyes at 6 months after levator resection. We investigated whether the degree of intraoperative lagophthalmos measured by calliper correlated with the preoperative values of MRD1, levator function and age. A stepwise multiple regression analysis was performed with intraoperative lagophthalmos as the dependent variable.
Results The mean intraoperative lagophthalmos was 7.4±0.9 mm (range, 6–10 mm). The intraoperative lagophthalmos was found to have a statistically significant negative correlation with preoperative MRD1 (r2 =0.55, p<0.0001) and levator function (r2 =0.53, p<0.0001), respectively. A stepwise multiple regression analysis resulted in the following regression formula: Intraoperative lagophthalmos=9.08 – 0.48×Preoperative MRD1 – 0.26×Levator function (r2 =0.60, p<0.0001).
Conclusion Intraoperative lagophthalmos in patients with satisfactory surgical outcome correlated negatively with both preoperative MRD1 and levator function and accounting for both variables resulted in a stronger correlation than either variable alone. Surgeons would be able to calculate the amount of surgical correction using this formula of intraoperative lagophthalmos, which could lead to a satisfactory surgical outcome in levator resection for congenital ptosis.
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.
Bahram Eshraghi, Hadi Ghadimi
To determine the rate of success of small-incision levator resection technique for correction of congenital ptosis.
Patients with congenital ptosis who were candidates for levator resection were enrolled if their levator function was not poor (< 5 mm). Incisions were made on upper eyelid crease with a length of 10–12 mm. After resection of adequate length of levator muscle, two sutures were used to fix it to tarsal plate. Sliding the incision to medial and lateral sides provided a wider field of access to allow the surgeon to place the sutures above nasal and temporal borders of limbus. Success was defined as margin reflex distance-1 (MRD-1) ≥ 3 mm and inter-eyelid difference of MRD-1 less than 1 mm, which was considered excellent if inter-eyelid difference was < 0.5 mm and good if the latter parameter was between 0.5 and 1 mm.
Fifty eyes of 47 congenital ptosis cases (16 males and 31 females) were included. Average age was 21.7 ± 9.7 years (range, 3–44 years). Mean preoperative levator function and MRD-1 were 11.26 ± 2.79 and 1.78 ± 0.92 mm, respectively, while postoperative MRD-1 increased to 3.95 ± 0.82 mm (P < 0.001). The result was failure (undercorrection) in 12 cases (25.5%), good in 9 patients (19.2%), and excellent in 26 cases (55.3%).
Small-incision levator resection has previously been studied for correction of aponeurotic ptosis and proved to yield successful outcome. The findings of this study suggest that small-incision technique can be effectively used in correction of congenital ptosis, as well.
Weaver, Daniel T.
Purpose of review Blepharoptosis is a common problem encountered in the pediatric ophthalmology clinic. The presentation is obvious to both parents and referring physicians and often prompts urgent consultation. The current classification and management of childhood ptosis will be reviewed.
Recent findings Recent refinements in techniques utilizing new materials hold promise for better, more predictable outcomes and improved long-term results. Autogenous tensor tendon fascia lata harvested from the patient’s thigh remains the gold standard for many ptosis surgeons in frontalis suspension; however, other materials are commonly utilized, including silicone rod, Gore-Tex (ePTFE; W.L. Gore & Associates, Flagstaff, Arizona, USA), Mersilene polyester fiber mesh and Ethibond braided polyester (Ethicon US LLC, Somerville, New Jersey, USA), Supramid monofilament nylon (S. Jackson, Inc, Alexandria, Virginia, USA), prolene, and banked fascia lata. Other techniques include levator resection, posterior approach levatorpexy, and Muller’s muscle conjunctival resection both with and without superior tarsectomy. Recent studies suggest that ptosis repair can be effectively combined with strabismus surgery.
Summary The management of ptosis in infants and children demands a structured and disciplined approach to avoid the development of amblyopia and long-term visual compromise. Underlying systemic problems must be identified and surgical planning discussed in a timely fashion with caregivers. Recent studies help to further define the proper timing of surgical intervention and the optimal techniques to provide the best long-term results for these patients.
Danesh, Jennifer; Ugradar, Shoaib; Goldberg, Robert; Joshi, Naresh; Rootman, Daniel B.
Purpose: The purpose of this study was to determine whether advancement of the levator aponeurosis in external levator resection surgery or Mueller’s muscle and conjunctiva in Mueller’s muscle conjunctival resection (MMCR) surgery has a differential effect on variation in eyelid position during the postoperative period.
Methods: In this retrospective observational cohort study, 2 groups of patients were defined. The first underwent MMCR surgery without tarsectomy by surgeon 1. The second underwent external levator resection without dissection posterior to the levator aponeurosis by surgeon 2. Marginal reflex distance (MRD1) was calculated based on digital photographs at baseline, 1 week postoperatively and at 3-month follow up. The primary outcome measure was change in MRD1 over time. The secondary outcome was defined as the proportion of patients with minimal early postoperative change (change of MRD1 less than 0.5 mm at 1 week postoperatively). Repeated measures analysis of variance, t test, and chi-square analyses were performed.
Results: Of the 114 eyes in the sample, there were 68 in the MMCR group and 46 in the external levator resection group. A significant interaction between group and time was noted (p < 0.05), indicating change in MRD1 over time was different between the groups. Bonferroni corrected multiple comparisons yielded significant differences between each time point for MMCR surgery (p < 0.01). No difference in MRD1 was noted for the external levator resection group from the early to late postoperative visit. Comparing each time point across groups revealed significantly lower MRD1 for the MMCR group at the early postoperative visit (p < 0.01). Preoperative and late postoperative MRD1 did not significantly differ between the groups. Regarding the secondary outcome, patients undergoing MMCR surgery were 3.7× as likely to demonstrate <0.5 mm of change in MRD1 at week 1 (p < 0.05). When considering the 39.7% (n = 27) MMCR patients in this category, 59.3% (n = 16) went on to show an MRD1 increase >1 mm from the early postoperative to the late postoperative time points.
Conclusions: Both external levator resection and MMCR can effectively elevate the eyelid in cases of primary involutional ptosis, and have similar late postoperative results. The authors found that MMCR cases undergo greater change between the early and late postoperative period, suggesting the process of eyelid elevation after MMCR may be dynamic, involving postoperative physiologic modification.