Can single stage surgery in Blepharophimosis syndrome be practiced universally?

Abstract

Dear Editor, We read the article Single stage surgery for Blepharophimosis syndrome’ by Bhattacharjee, et al.[1] We do agree with the authors that single stage surgery is a useful approach, but it can’t be practiced as a blanket treatment. Although the minimum age of patients in this article was 6 years and fascia lata was used for correction of ptosis, many of them present before starting the school and require early ptosis surgery to prevent amblyopia.[2] Fascia lata is not sufficiently developed as a donor material until the child is 3 to 4 years of age, and other sling materials like preserved fascia lata and silicon rods have to be used.[3] The use of other sling materials shortens the operative time, especially in a single stage surgery and may also be considered otherwise in children >4 years. BPES may be associated with strabismus in 26.7% cases and may require additional surgery at a later date.[2] The authors have performed a lateral canthotomy and canthoplasty for correction of palpebral phimosis and enlargement of eyelid fissure at an initial stage.[1] However, the lateral canthotomy done to open up the palpebral aperture is not preferred as it leads to loss of definition of natural canthus with tendency for erythematous conjunctiva to creep over the newly created sector of lid margin. The lid stretches in time after medial canthopexy, obviating the need for lateral canthotomy altogether.[4] The method used for measurement of superior visual field defect is not described in the article. Also, the defect does not seem to co-relate with the severity of ptosis as per Table 2.[1] Furthermore, the visual fields in a 6-year-old child can’t be measured reliably and are best excluded from the analysis. BPES can be associated with systemic involvement, difficult airway, and rarely with congenital heart disease posing challenges in anesthetic management.[5] Therefore, single stage surgery can be performed successfully but only in a select group of patients suffering from BPES.