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.
Preamjit Saonanon & Panida Potita
Purpose: To evaluate pre- and post-operative marginal reflex distance 1 (MRD1) when conducting Mueller’s muscle-conjunctiva resection (MMCR) on the normal eyelid of thyroid eye disease (TED) patients with unilateral eyelid retraction.
Methods: This was a retrospective non-comparative case series. Medical records of TED patients with unilateral eyelid retraction, who underwent a contralateral MMCR from November 2015 to September 2017, were reviewed. Standard photographs of pre-operative, post-phenylephrine test and post-operative were measured for eyelid positions including MRD1, MRD2 and inter-palpebral fissure width. MMCR was indicated on the contralateral eyelid only in patients who had a cosmetically acceptable result from phenylephrine test and were willing to receive the operation on the normal eye.
Results: Twelve TED patients who underwent MMCR on the normal eyelid were included in the study. Mean pre-operative MRD1 of retracted and normal eyelid were 5.7 mm (SD = 0.86) and 3.5 mm (SD = 0.65), respectively. Mean post-operative MRD1 of retracted and normal eyelid were 4.4 mm (SD = 0.76) and 4.1 mm (SD = 0.46), respectively. The asymmetry of MRD1 between eyes was significantly decreased from 2.1 mm (inter-quartile range (IQR) = 1.5–2.9 mm) pre-operatively to 0.3 mm (IQR = 0.1–0.7 mm) post-operatively (p = .002). None of these patients needed further eyelid correction surgery and there was no complication.
Conclusions: In TED patients with unilateral eyelid retraction, using phenylephrine test on their normal eyes should be initiated. If eyelid position was satisfactorily equalized, performing MMCR on the normal eyelid is considered an effective alternative treatment with a predictable outcome.
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.
Feldman, Ilan; Brusasco, Lucas; Malhotra, Raman
Purpose: The authors present a new series of our experience using posterior approach levatorpexy for congenital ptosis with poorer levator function (LF) in comparison with our first published report. This technique avoids a skin incision or any resection in addition to no excision of tissue.
Methods: A consecutive series of 16 patients. Retrospective review of levatorpexy for congenital ptosis. Data included eyelid margin reflex distance 1, pretarsal show, contour, and complications, including nocturnal lagophthalmos, eyelid lag on downgaze, and dry eye. Surgery was considered successful if the following 4 criteria were simultaneously met: a postoperative margin reflex distance 1 of ≥2 mm and ≤4.5 mm, intereyelid height asymmetry of ≤1 mm, no overcorrection compare to opposite eye, and satisfactory eyelid contour.
Results: Mean age was 10.3 years (range 1–26 years). Mean LF was 7.3 mm (2–14 mm), while 66% (12) had LF ≤7 mm. Preoperative phenylephrine test was positive in 87.5% of patients. Mean preoperative and postoperative margin reflex distance 1 was 1.34 mm and 3.2 mm, respectively. Fourteen patients (87%) achieved the desired eyelid height and fulfilled our criteria set of success. Among 10 patients with LF ≤7 mm, 9 (90%) achieved the desired eyelid height and fulfilled our criteria set of success. Ninety-four percent did not report nocturnal lagophthalmos. Three patients needed a further levatorpexy procedure due to undercorrection. Mean postoperative follow up was up 11.2 (range 6–36) months.
Conclusions: Posterior approach levatorpexy is an useful first-line choice for congenital ptosis for all ranges of LF. It is popular among parents due to its avoidance of a skin incision or any resection or excision of tissue.
H Matsuda, T Shiba, Y Takahashi and H Tsuneoka
To analyse the relationship between the results of the phenylephrine test and postoperative eyelid droop in transcutaneous aponeurotic repair using epinephrine-containing local anaesthetic for aponeurotic blepharoptosis.
Patients and methods
We retrospectively reviewed the medical records of 66 eyelids from 40 patients who underwent transcutaneous aponeurotic repair. A positive phenylephrine test result was defined as an increase in margin reflex distance-1 (MRD-1) ≥0.5 mm after application of phenylephrine eye drops. The patients were divided into a positive phenylephrine response group (Group A, 16 patients) and a negative phenylephrine response group (Group B, 24 patients). The ΔMRD-1 was calculated by subtracting the 3-month postoperative value from the intraoperative value. Patient age, sex, pre- and intraoperative MRD-1s, levator function, and phenylephrine response were investigated as factors potentially influencing the ΔMRD-1. The relationship between these factors and ΔMRD-1 was analysed using single and multiple regression analysis.
The ΔMRD-1 in Group A (0.68±0.52 mm) was significantly greater than that in Group B (0.17±0.56 mm; P=0.004). A moderate correlation was found between phenylephrine response and ΔMRD-1 in the total patient group (YΔMRD-1=0.441 Xphenylephrine+0.358; r=0.462; r2=0.213; P=0.002).
Although the ΔMRD-1 in Group B was quite small, the ΔMRD-1 in Group A was considerable, and there was a moderate positive correlation between phenylephrine response and the ΔMRD-1 overall. This indicates that the degree of postoperative eyelid droop can be estimated by the phenylephrine test results in transcutaneous aponeurotic repair.
G. N. Thomas, J. Chan, G. Sundar & S. Amrith
Both the Müller muscle-conjunctiva resection (MMCR) and levator advancement (LA) procedures can be used to manage ptosis in patients with good levator function. The aim of this article is to evaluate the efficacy and cosmetic outcomes of the two procedures. The clinical records of 29 consecutive eyelids of 26 patients undergoing MMCR and 30 eyelids of 23 patients undergoing LA were analysed. Eleven (42%) in the LA group and 9 (39%) in the MMCR group were male. The preoperative eyelid measurements were significantly different in the LA compared to the MMCR groups, in terms of palpebral aperture (PA) (6.3 vs 7.4, p = 0.01), marginal reflex distance 1 (MRD1) (-0.1 vs 1.5, p < 0.001) and levator function (LF) (12.1 vs 13.4, p = 0.03). The MRD1 1 month post-surgery was slightly less in the LA group compared to the MMCR group (2.6 vs 3.18 mm, p = 0.047) but not significantly different at months 3 and 6. The final change in MRD1 was significantly higher in the LA group (2.93 vs 1.76, p = 0.004). The MMCR group had a lower incidence of lid contour abnormalities (0% vs 20%, p = 0.01) and overcorrection (0% vs 13%, p = 0.04). There was no statistically significant difference in the rates of undercorrection in either group. Both the MMCR as well as LA procedures are effective for mild to moderate ptosis in patients with good levator function. Patients undergoing MMCR had higher success rates, better preservation of the natural lid contour, and a lower incidence of overcorrection than patients undergoing LA.