Aponeurotic Ptosis Research Articles

Relative Incidence of Blepharoptosis Subtypes in an Oculoplastics Practice at a Tertiary Care Center

Purpose: In patients referred with blepharoptosis, the possibility of an underlying systemic cause for their ptosis can warrant a more detailed evaluation. The purpose of this study is to determine both the incidence and demographic characteristics associated with different types of ptosis in patients referred to the oculoplastics division at a tertiary care center.Methods: A retrospective chart review was performed on all patients referred to the oculoplastics division between 2007 and 2010. Final etiology for each patient’s ptosis was determined based on history, standard eyelid measurements, and ancillary testing. Based on etiology, ptosis was categorized as aponeurotic, neurogenic, myogenic, traumatic, congenital, or mechanical. Demographics, including median age and sex were analyzed for patients in each category of ptosis.Results: Of the 251 patients, aponeurotic ptosis was the most common type of ptosis (60.2%), followed by traumatic (11.2%), congenital (10.4%), mechanical (8.8%), neurogenic (5.6%), and myogenic (4.0%). Of the neurogenic group, 35.7% of patients had cranial nerve 3 (CN 3) palsy, 28.6% had myasthenia gravis, 14.3% had aberrant regeneration, and 7.1% had Horner’s syndrome. Thirty percent of the myogenic group had chronic progressive external ophthalmoplegia (CPEO). The congenital group had the youngest median age (10.5 years), yet the aponeurotic group had the oldest (62 years).Conclusions: A significant proportion of patients referred with ptosis had more serious conditions such as neurogenic or myogenic ptosis. Thus, clinicians should maintain a high degree of suspicion and thoroughly evaluate all patients with ptosis in order to properly assess for underlying systemic associations.

The role of apoptosis in blepharoptosis

The purpose of this study is to evaluate the role of apoptosis in the pathogenesis of blepharoptosis. Forty-five eyelids of 43 consecutive patients (16 female, 27 males) that underwent levator resection surgery for ptosis correction were included in the study. Twenty-six of the eyelids had congenital myogenic ptosis and 19 had aponeurotic ptosis. Levator palpebrae superioris function and height of the vertical palpebral fissure were measured in all patients. After levator resection surgery, the distal part of the levator aponeurosis was fixed and sent for evaluation. Apoptotic cells were detected using Apop Tag Plus Peroxidase In Situ Apoptosis Detection Kit. The mean levator palpebrae superioris function was 8.4 mm (range 5-10 mm) in congenital ptosis group and 12.1 mm (range 10-17 mm) in the aponeurotic ptosis group. The mean height of the vertical palpebral fissure in patients with congenital ptosis and aponeurotic ptosis were 6.5 mm (range 5-9 mm) and 6.1 mm (3-9 mm), respectively. The mean apoptotic index of congenital ptosis and aponeurotic ptosis were 27.3 (16-39) and 29.8 (18-41), respectively. There was no statistically significant difference between congenital and aponeurotic ptosis groups in a mean apoptotic index (P<0.05). Apoptotic index was not correlated with age, levator palpebrae superioris function, palpebral fissure height, and lid crease height in two groups. We found no statistically significant difference between two subtypes of blepharoptosis regarding apoptosis. According to this study, apoptosis seems to have no significant role in the development of aponeurotic blepharoptosis.

Outcomes of Adult Aponeurotic Ptosis Repair Under General Anaesthesia by a Posterior Approach White-Line Levator Advancement

Aponeurotic ptosis surgery is conventionally performed under local anaesthetic to allow adjustment of eyelid height and contour. This may not be possible where general anaesthesia (GA) is required.Purpose: We describe our experience using a tranconjunctival posterior approach “white-line” levator advancement (WLA) in patients undergoing aponeurotic ptosis correction under a GA.Materials and Methods: Retrospective review of a consecutive series of 20 patients with primary aponeurotic ptosis undergoing posterior approach WLA ptosis repair under GA. The procedure involves exposing the posterior surface of the levator aponeurosis and advancement through tarsus onto its anterior surface if exposed already, or to skin. All patients underwent pre- and postoperative photographs and final outcomes were assessed at minimum 3 months. Outcome measures included pre- and post-marginal reflex distance (MRD), symmetry of height, contour, fold and complications including dry eye.Results: Twenty patients undergoing 40 procedures were included. Mean age was 58 (22–87) years. Mean preoperative MRD was 1.3. Preoperative phenylephrine test was positive all patients. The mean postoperative MRD was 3.5 mm. Although all 20 patients achieved their desired lid height and contour, one patient had a 2 mm asymmetry, with a final success rate of 95% (19/20 patients).Conclusion: We suggest that a posterior approach white-line advancement is an ideal technique to correct even severe aponeurotic ptosis in patients requiring surgery under GA. Preoperative positive phenylephrine test is a good predictor of postoperative height and contour without the need for per-operative adjustment.Précis: Aponeurotic ptosis surgery for patients under general anaesthesia using a simple posterior approach white-line advancement achieves predictability of lid height, symmetry and contour and is an ideal option for phenylephrine-positive ptosis.

Outcome Following Surgery for Contact Lens-Induced Ptosis

To assess the outcome of surgery in patients with a history of contact lens wear. Retrospective, comparative interventional case series. A total of 419 patients underwent ptosis surgery during a 1-year period (2005-2006) at Moorfields Eye Hospital. Those included in this study had a diagnosis of aponeurotic ptosis and history of contact lens wear. The outcome was considered a success if the following criteria were met: 1) a margin reflex distance of between 3 and 5 mm, 2) an interlid difference of 1 mm or less, and 3) absence of redo surgery. Thirty patients (7.2%) were identified with a history of contact lens wear and were matched against a control group of 46 patients. The mean margin-reflex distance at presentation was 0.5 ± 2.4 mm. This equated to a ptosis graded as mild (≥1.5 mm) for 32% of patients, moderate (0.5-1.0 mm) for 29%, and severe (≤0.0 mm) for 39%, with similar proportions in the control group (36% mild, 39% moderate, and 25% severe). The power of the refractive correction (p < 0.005) and the age of the patient (p < 0.05) were directly related to increased severity of ptosis at presentation. The surgical outcome of the ptosis correction was successful in 72% of patients, which was significantly lower than in the control group (89%) (p < 0.005). The severity of contact lens-related ptosis was related to the degree of myopia and the age of the patient but not to the duration of contact lens wear. There was a higher level of failure and requirement for redo surgery in patients with contact lens-related ptosis compared with matched controls.

Double-eyelid blepharoplasty incorporating blepharoptosis surgery for ‘latent’ aponeurotic ptosis

Most of the patients who undergo double-eyelid blepharoplasty report satisfactory cosmetic results. However, it remains some complications such as the failure to create double-eyelid skin creases and the outcome of higher skin creases and asymmetrical upper eyelids. These complications may happen even when the surgery proceeded successfully and the septum was intact, which suggested that the aponeurosis could not been damaged. Between January 2008 and June 2009, 39 patients (51 eyes, 7.75%) who requested double-eyelid blepharoplasty were found to display 'latent' aponeurotic ptosis. In these patients, the aponeuroses were disinserted from the tarsus or attenuated and elongated. All of these patients agreed to undergo aponeurotic ptosis correction along with double-eyelid surgery, of which 34 (45 eyes, 88.24%) were deemed successful. We believe that the careful measurement of ptosis in cosmetic patients will help to identify patients with 'latent' aponeurotic ptosis. Incorporation of the aponeurotic reinsertion and minimal dissection into the blepharoptosis surgery will correct the 'latent' aponeurotic ptosis successfully.

Transconjunctival Levator Aponeurosis Advancement without Resection of Müller’s Muscle in Aponeurotic Ptosis Repair

The transconjunctival levator aponeurosis advancement without resection of Müller’s muscle enables repair of aponeurotic ptosis without the need for surgical exposure through a skin incision. This technique may be preferred by many patients who are reluctant to undergo ptosis surgery because of the possible skin scar and who do not present with excessive upper eyelid laxity. A successful outcome requires careful patients' selection, familiarity with the surgical anatomy of the everted eyelid, as well as with the possible complications. Special consideration should be given to factors such as determining the degree of aponeurosis advancement to accord with the height of the eyelid during surgery and to creating the desired shape and size of the “double eyelid” in Asians. From our experience, this surgical technique is effective in correcting levator aponeurotic ptosis and contributes to a quick recovery of the normal anatomy and function of the eyelid. This method should therefore be added to the arsenal of techniques for blepharoptosis repair.

Transconjunctival Blepharoptosis Surgery: A Review of Posterior Approach Ptosis Surgery and Posterior Approach White-Line Advancement

Posterior approach blepharoptosis surgery, via the transconjunctival route, was probably the first method of surgery employed to shorten the levator palpebrae superioris (LPS) muscle. A review of the literature demonstrates how surgery has evolved since Blaskovics’ first described his technique in 1923. We describe our newer method of posterior approach white-line advancement blepharoptosis repair which is now an option in the majority of aponeurotic ptosis with moderate to good levator function.

Posterior approach white line advancement ptosis repair: the evolving posterior approach to ptosis surgery

IntroductionWe describe a surgical technique for ptosis correction in moderate to good levator function involving advancement of the levator aponeurosis via a transconjunctival posterior approach without resection of Müller's muscle....

British Oculoplastic Surgery Society (BOPSS) National Ptosis Survey

Aim:To assess the results of primary aponeurotic ptosis surgery among UK ophthalmic oculoplastic surgeons, from both the surgeon’s and patient’s perspective; also to inform and encourage good clinical practice by...

Inverse Bell's Phenomenon Following Repeated Levator Resection Surgery

Purpose: We report a complication involving a transient inversion of Bell's phenomenon observed following extensive levator resection performed to treat aponeurotic ptosis. Case summary: A 22 year old female patient complained of ptosis of both eyelid. The levator function of both lid was good, and a normal corneal protection mechanism was observed. The patient underwent levator resection and several reoperation because of asymmetrical lid height and entropion. Inversion of Bell's phenomenon was observed in the postoperative period. Eye with Bell's phenomenon reverted to normal within 1 month after final operation, and there were no corneal erosion. Lubricating eyedrop was used frequently during the postoperative period. Conclusions: It is important to consider that abnormal cases of Bell's phenomenon sometimes manifest after repetitive and extensive levator resection and to keep a close watch on the cornea while providing it with ample lubrication.

Autosomal Dominant Early Onset Aponeurotic Ptosis and Corneal Limbal Vascularization in a Three-generation Family

A novel phenotype in a 3-generation family with early-onset aponeurotic ptosis and corneal limbal vascularization is described. Karyotype analysis was normal in the proband, and autosomal dominant transmission is demonstrated.

Assessment of the Predictive Value of Intraoperative Eyelid Height Measurements in Sitting and Supine Positions During Blepharoptosis Repair

To examine relationships between intraoperative and postoperative eyelid heights in relation to patient postures in blepharoptosis surgery. Thirty eyelids in 15 patients with bilateral aponeurotic ptosis were selected. The margin reflex distance-1 (MRD-1) was measured with the patients in the sitting position preoperatively, intraoperatively, and in the postoperative 6 weeks. MRD-1 also was measured intraoperatively with patients in the supine position. The intraoperative sitting and supine values and the postoperative values were statistically compared using a paired t test, and lateralities in those groups were statistically analyzed using Student's t test. From the intraoperative measurements, mean MRD-1 values in the sitting position (right: 3.80 mm, left: 3.73 mm) were significantly lower than those in the supine position (right: 4.37 mm, p < 0.001; left: 4.33 mm, p < 0.001). In the postoperative 6 weeks, mean MRD-1 values (right: 3.80 mm, left: 3.63 mm) were not significantly different from intraoperative values in the sitting position (right: p = 1.000, left: p = 0.189), but were significantly lower than intraoperative values in the supine position (right: p < 0.001, left: p < 0.001). There was no significant laterality among the three groups (supine intraoperative: p = 0.890, sitting intraoperative: p = 0.785, postoperative: p = 0.546). Intraoperative measurements in the sitting position more accurately predicted postoperative eyelid height than did measurements with the patient in a supine position.

Miastenia grave ocular: aspectos diagnósticos y evolución

Myasthenia gravis lacks a diagnostic gold standard, so diagnosis is supported by the findings of several tests. Conversion from ocular myasthenia gravis (OMG) to a more widespread disease is frequently early. AIMS. To describe and compare the clinical data and findings of the diagnostic tests of patients with OMG and those with a different diagnosis, and to know the conversion rate from OMG to generalized myasthenia. Descriptive and analytic retrospective study of 44 patients referred for neurophysiological testing through 4 years because of suspected OMG. 12 patients (27%) were diagnosed as having OMG. Evolution time prior to diagnosis tended to be shorter in OMG patients. Isolated ptosis or combined with diplopia was more frequent in OMG, while isolated diplopia was so in other diagnoses (<I>p</I> = 0.003). No thymoma was found. SFEMG jitter of facial muscles was abnormal, including blocking, in all OMG patients (8/8) and normal in the rest (30/30). Edrophonium test was positive in all OMG patients (7/7) and doubtful in another one (1/7). Anti-AChR titers were initially positive in 10/11 OMG patients and 0/17 with other diagnoses. Aponeurotic ptosis and strabismus were the most frequent non-myasthenic etiologies. OMG showed an early generalization in two patients who developed dysarthria. The low ratio of diagnostic confirmation suggests that in the face of ptosis or diplopia diagnostic testing with a high sensibility for OMG is favoured. Jitter showed the best initial diagnostic performance.

The role of Botulinum toxin in correcting frontalis-induced eyelid pseudo-retraction post ptosis surgery

We report a case of a 52-year-old female patient who developed overcorrection, due to brow overuse, post surgery for bilateral aponeurotic ptosis. The patient had undergone levator palpebrae superioris plication bilaterally. Due to brow overuse habituated by long standing ptosis, the patient presented with superior scleral show, post ptosis surgery. The lid contour was normal in both eyes and when brow overaction was blocked mechanically, the palpebral fissure heights were normal, comparable, with no scleral show bilaterally. Despite repeated instructions, when the patient continued brow overuse subconsciously, an injection of botulinum toxin was given just above both brows. This led to elimination of brow overuse within a month, with elimination of superior scleral show. The patient maintained lid and brow symmetry with no overaction, eight months post injection.

Efficacy and efficiency of a small-incision, minimal dissection procedure versus a traditional approach for correcting aponeurotic ptosis

To compare the efficacy and efficiency of a new small anterior incision, minimal dissection ptosis procedure with that of a traditional anterior aponeurotic approach for the correction of aponeurotic ptosis. Retrospective, comparative, interventional case series. Seventy-two patients with aponeurotic ptosis who had undergone ptosis correction surgery by 1 surgeon: 36 patients (49 ptotic eyelids) who had ptosis correction by a small-incision, minimal dissection procedure and 36 patients (49 ptotic eyelids) who had ptosis correction by a traditional aponeurotic approach. Charts and available photographs were reviewed for each patient. Postoperative upper eyelid height relative to the center of the pupil and relative to the opposite upper eyelid and the postoperative eyelid contour. Successful correction of the eyelid height and the rate of recommended reoperation were not significantly different for the 49 lids corrected in each arm of the study. The incidence of attaining good eyelid contour was significantly better in the small incision group, in which 41 of 42 lids (97.6%) evaluated by photographs had good contour compared with 29 of 37 lids (78.4%) in the traditional group. Operating time per lid was significantly less for the small-incision, minimal dissection group, 25.3+/-13.0 minutes (range, 13-68 minutes) compared with 55.4+/-16.6 minutes (range, 35-119) for the traditional group. The small-incision, minimal dissection technique for ptosis correction is equally effective in correcting eyelid height, superior in producing desirable eyelid contour, and much quicker to perform than the traditional aponeurotic approach.

No-scar Asian epicanthoplasty: a subcutaneous approach.

The epicanthal fold is a normal finding in the medial portion of the upper eyelid in many Asians. We describe a simple technique of removing the excess muscle and softening or eliminating the epicanthal fold without making incisions in the medial canthal region, thus avoiding complications such as scarring or web formation Interventional case series. The subcutaneous epicanthoplasty was performed on all Asian patients undergoing concurrent upper eyelid blepharoplasty or aponeurotic ptosis repair. Thirty-eight Asian patients underwent epicanthal fold correction between January 1996 and December 2000. All patients had softening of the epicanthal fold; however, some cases of mild undercorrection were noted. Softening or elimination of the Asian epicanthal fold can be accomplished without making skin incisions in the medial canthal region. Our technique is a simple, graded procedure that can be performed in conjunction with upper blepharoplasty or ptosis repair.

Incidence of lagophthalmos after aponeurotic ptosis repair

Incidence of lagophthalmos after aponeurotic ptosis repair

Incidence of lagophthalmos after aponeurotic ptosis repair

This study was designed to determine the incidence of lagophthalmos following aponeurotic ptosis repair, and to establish any predictive factors for its development. Data from a prospective, interventional, non-comparative case series was reviewed. Of these 164 eyelids with acquired involutional ptosis, 134 eyelids of 75 patients had both preoperative and postoperative photographs of the eyelids in the primary and gently closed positions, and were therefore analyzed for this study. Lagophthalmos was present in 23/38 (60%) of eyelids on the first postoperative day; in 27/81 (33%) one week after surgery; and persisted in 12/134 (9%) eyelids and 8/75 (11%) patients six to twenty weeks after surgery (mean 11 weeks). The lagophthalmos of these twelve eyelids ranged from 0.5 to 1.5 mm with a mean of 0.6 mm. Both the pre-existing lower scleral show and the final height of the eyelid following surgery were significant predictors of postoperative lagophthalmos. Neither eyelid excursion nor the degree of change in eyelid height from pre- to post-surgery was significantly associated with eyelid closure.

Stabilization of eyelid height after aponeurotic ptosis repair

ObjectiveTo develop guidelines for revision of ptosis surgery in the early postoperative period by establishing what percentage of eyelids after anterior levator advancement have reached their final height by the first postoperative week. DesignProspective noncomparative case series. ParticipantsAn analysis was performed on 164 eyelids in 97 patients with involutional aponeurotic ptosis. InterventionAnterior levator advancement was performed on each of these 164 eyelids. Exclusion criterion consisted of a history or evidence of neurologic or muscular disease, preceding trauma, an anophthalmic socket, or prior eyelid surgery. Main outcome measuresThe marginal reflex distance, eyelid excursion, and degree of swelling were recorded perioperatively; additionally, photographs were obtained before surgery and at 1 and 6 weeks after surgery. ResultsAt 1 week after surgery, only 40% of eyelids had reached their final height; 52% continued to rise a mean of 1.1 mm. The percentage of eyelids continuing to rise after the first postoperative week varied with the amount of swelling present at 1 week, although a direct correlation did not exist (Pearson correlation, 0.22; P < 0.26). Although this increase ranged from 0.5 to 3.0 mm for 71% of eyelids, the subsequent increase was 1 mm or less. Maximal eyelid height was achieved almost universally by 6 weeks, after which 18% of eyelids subsequently dropped a mean of 0.8 mm. ConclusionsBased on this study, the authors suggest revision at 1 week after anterior levator advancements in which minimal-to-moderate eyelid swelling exists for contour abnormalities, if the eyelid height is 0.5 mm or more above or more than 1.0 mm below the target height, or if asymmetry between the eyelids is 1.0 mm or more. The authors do not advise early revision for patients with excessive swelling still present 1 week after surgery.

Evaluation of Levator Muscle Integrity in Ptosis with Levator Force Measurement

To determine the efficacy of the force the levator muscle can generate as a diagnostic tool for ascertaining the cause of ptosis. A total of 187 patients with ptosis were evaluated clinically, their levator force was measured, and each ptotic eyelid subsequently had surgical correction. At each step, patients received a diagnosis of congenital or acquired (history- dependent) aponeurotic, myogenic, neurogenic, or mechanical ptosis. To measure the levator force, a clamp placed on the upper eyelid lashes was attached to a force transducer. The maximum force generated on upgaze was recorded as the levator force. Data from healthy subjects were used to determine whether each levator muscle of the ptotic eyelids produced normal or less than normal force. The correct diagnosis was considered to be the diagnosis based on the findings at the time of surgery. The diagnosis of each patient with ptosis determined by eyelid excursion, eyelid excursion plus examination, levator force, and the levator force plus examination results were compared with the correct diagnosis. Eyelid excursion predicted the correct diagnosis 78.2% of the time. When eyelid excursion was combined with the examination results, the diagnosis was correct 84.0% of the time. Levator force predicted the correct diagnosis 95.2% of the time. When levator force was combined with the examination, the diagnosis was correct 97.9% of the time. Diagnosis of the cause of ptosis based on levator force measurement is significantly more accurate than when the diagnosis is based on eyelid excursion, even when information obtained on examination also is considered. Levator force measurement should be an integral part of ptosis evaluation.