Asymmetric Ptosis Research Articles

Neuromuscular junction in amyotrophic lateral sclerosis. Is there more to follow?

Background. Amyotrophic lateral sclerosis (ALS) causes progressive degeneration of upper motor neurons in the cortex, and lower motor neurons in the spine. In addition, it is unclear where motor neuron dysfunction begins and what causes motor neuron degeneration: whether it is the dying forward process or the dying back phenomenon where motor neuron degeneration begins distally at the nerve terminal or at the neuromuscular junction and progresses toward the cell body, is still a matter of debate. Materials and methods. Are there neuromuscular junction disorders in the early stages of ALS? To answer this, we described 5 patients with ALS presented at Petre Sarajishvili Institute of Neurology in 2018–2022, 3 males and 2 females aged 50–61 years. ALS diagnosis was based on clinical signs, the Gold Coast criteria, electromyography (Awaji), neuroimaging, blood and urine tests. At the early stage of the disease, only asymmetric ptosis and diplopia were noted, which did not improve on pyridostigmine or steroids. Results. We studied patients’ anamnesis, physical data, evaluated their mental, cognitive functions and neurological status. We have also interviewed family members, as it was often difficult for the patient to accurately describe the symptoms. Acetylcholine receptor antibodies were mildly positive only in one patient. Thymoma was excluded. The neurophysiological study showed only marked neuromuscular transmission failure in orbicularis oculi, there were no clinical and electromyographic signs of motor neuron damage. Conclusions. Approximately 2 years later, all five patients developed clinical and electromyographic signs of ALS. In the present study, neuromuscular junction disorders are found to play an important role in the pathogenesis of ALS and may serve as a useful early diagnostic marker.

Uraemic brainstem encephalopathy mimicking ocular myasthenia: a case report

BackgroundUraemia causes a generalised encephalopathy as its most common neurological complication. Isolated brainstem uraemic encephalopathy is rare. We report a case of fatigable ptosis and complex ophthalmoplegia in brainstem uraemic encephalopathy.Case presentationA 22-year-old Sri Lankan man with end stage renal failure presented with acute onset diplopia and drooping of eyelids progressively worsening over one week. The patient had not complied with the prescribed renal replacement therapy which was planned to be initiated 5 months previously. On examination, his Glasgow coma scale score was 15/15, He had a fatigable asymmetrical bilateral ptosis. The ice-pack test was negative. There was a complex ophthalmoplegia with bilateral abduction failure and elevation failure of the right eye. The diplopia did not worsen with prolonged stare. The rest of the neurological examination was normal. Serum creatinine on admission was 21.81 mg/dl. The repetitive nerve stimulation did not show a decremental pattern. Magnetic resonance imaging (MRI) of the brain demonstrated diffuse midbrain and pontine oedema with T2 weighted/FLAIR hyperintensities. The patient was haemodialyzed on alternate days and his neurological deficits completely resolved by the end of the second week of dialysis. The follow up brain MRI done two weeks later demonstrated marked improvement of the brainstem oedema with residual T2 weighted/FLAIR hyperintensities in the midbrain.ConclusionsUraemia may rarely cause an isolated brainstem encephalopathy mimicking ocular myasthenia, which resolves with correction of the uraemia.

The Prevalence and Severity of Acquired Blepharoptosis in US Eye Care Clinic Patients and Their Receptivity to Treatment.

To assess the presence and severity of acquired blepharoptosis (ptosis) among patients visiting an eye care clinic and the receptivity of eligible patients to pharmacologic treatment with oxymetazoline 0.1% ophthalmic solution. Patients aged 50 years or older who had a scheduled clinic appointment for any reason (eg, dry eye, cataract surgery consultation) were asked to respond to written questions about lid position and select whether their upper lid position most closely matched one of 4 images shown to them corresponding to no, mild, moderate, or severe ptosis. Patients selecting any of the mild, moderate, or severe ptosis were offered treatment with oxymetazoline 0.1% ophthalmic solution, barring any medical contraindications. The outcome measures were the proportion of patients with each self-reported lid position level (none to severe ptosis), the proportion of patients with asymmetric ptosis, and the proportion of patients willing to accept the treatment. Data for 188 eyes of 94 patients were analyzed. Overall, 73.4% of patients had ptosis in at least one eye, and 25.5% had an asymmetric upper eyelid presentation. The proportions of patients with self-reported mild, moderate, or severe ptosis in at least one eye were 41.5%, 25.5%, and 6.4%, respectively. Among those patients eligible for treatment, 19.7% were willing to accept the treatment. Based on patients' self-assessment of lid position, this study suggests a higher prevalence of ptosis than reported previously. Evaluation of the eyelids should be a standard part of the comprehensive eye examination.

Teaching Video NeuroImages: Useful bedside testing for myasthenia gravis

During examination of a 62-year-old woman with a diagnosis of myasthenia gravis, left eyelid manual elevation caused exacerbated ptosis on the right (enhanced ptosis) (figure). According to Hering law, there is approximately equal innervation of the levator palpebrae superioris muscles in both eyelids.1 In an asymmetric ptosis, the motor impulses increase to compensate ptosis on the more affected side but also flow to the contralateral eyelid, which mitigates ptosis on that side. With manual elevation of the more affected eyelid, the need to sustain eyelid elevation is relieved, and there is an attenuation of these motor impulses causing ptosis enhancement of the other eyelid (video 1).2

Optimizing Management of Asymmetric Ptosis: A Comparison of Three Posterior Approach Resection Algorithms.

The purpose of this study was to compare the efficacy of 3 resection algorithms in the management of patients with asymmetric ptosis. Patients undergoing bilateral Muller's muscle-conjunctival resection (MMCR) were identified. Standardized preoperative clinical photographs were examined and margin reflex distance 1 (MRD1) was measured using ImageJ. Patients presenting with ≥1 mm of asymmetry in MRD1 were included. Three groups were identified: variable (4:1 ratio, with the lower side receiving a greater resection), fixed (7 mm resection bilaterally), and tarsectomy (7 mm bilaterally + 1 mm of tarsus resected on the lower preoperative side). Postoperative MRD1 was measured from photographs obtained 3 months after surgery. The primary outcome was postoperative asymmetry. A total of 95 patients with a mean age of 71.0 ± 11.0 years were included. There was no significant difference in age ( p = 0.277) or length of follow-up ( p = 0.782) between the groups. Although the fixed tarsectomy group had significantly greater preoperative asymmetry ( p = 0.001), there was no significant difference in postoperative asymmetry ( p = 0.166). On multivariate analysis, preoperative asymmetry was the only significant predictor of postoperative asymmetry ( p < 0.001). Specifically, the surgical group was not a predictor of the primary outcome ( p = 0.723). Resection amount and technique did not predict postoperative outcomes in cases of asymmetric ptosis. This may support the hypothesis that changes in eyelid position and symmetry following MMCR is due to a dynamic system, rather than as a result of purely mechanical forces.

Myasthenia gravis and pregnancy: impact and approach

Myasthenia gravis is characterized by skeletal muscle weakness, the most common initial presentation includes ocular weakness with asymmetric ptosis and binocular diplopia. Around 19-50% of pregnant women with myasthenia gravis will experience a worsening of the disease. The objective of this article was to review the current information regarding the interrelation between MG and pregnancy; as well as its approach. Bibliographic search in databases such as PubMed, ScienceDirect, SciELO, Google Scholar and medRxiv. Original articles, reviews, series and case reports between 2013 and 2022 are included. Myasthenia gravis would not significantly effects on pregnancy; however, pregnancy can exacerbate the disease, especially during the first trimester or after delivery. The approach to pregnant women with myasthenia gravis must be multidisciplinary and involves the adjustment of pharmacological treatment and constant monitoring.

Pronounced Ptosis in Myasthenia Gravis-A New Bedside Clinical Sign.

We report three cases of myasthenia gravis in whom the asymmetrical ptosis at presentation became more pronounced with the described bedside technique. Pronounced ptosis could be elicited by making the patient speak continuously for up to 2 minutes. Pauses for breathing and natural blinking were allowed. The sign is best elicited in newly diagnosed and treatment-naive patients. The loss of compensation for ptosis by frontalis muscle due to speech-induced fatigue may be responsible for the observed effect. Patients’ symptoms abated on treatment with acetylcholine esterase inhibitors, steroids, and steroid-sparing agents.

Prise en charge du syndrome de blépharophimosis ptôsis épicanthus inversus (SBPE) dans un centre de référence en Tunisie

Blepharophimosis ptosis epicanthus inversus syndrome (BPES) is a rare congenital hereditary abnormality. It includes complex orbital-palpebral malformations, causing aesthetic and functional ramifications. Management of BPES requires two steps: diagnosis and treatment. We performed a retrospective descriptive study of 44 patients (88 eyelids) with blepharophimosis-ptosis-epicanthus inversus syndrome (BPES). In our series, we opted for two-stage surgery in 28 cases: epicanthus-telecanthus surgery followed by ptosis surgery. Simultaneous surgery was performed in 5 cases. The mean age at the first visit was 6 years (6.1±6.4). The mean age of our patients at the time of the first surgery was 6.6 years. Epicanthus surgery was performed in 35 cases. The two techniques used to correct epicanthus were Y-V plasty in 30 cases (85.7%, n=35) and Y-V+double Z plasty in 5 cases (14.3%, n=35). Correction of the telecanthus was performed at the same time by a medial canthal tendon plication in 31 cases (88.6%, n=35) or transnasal canthopexy in 4 cases (11.4%, n=35). The mean age at the time of ptosis surgery was 7.23 years (±6.25), ranging from 8 months to 27 years. Ptosis surgery was performed in 41 cases (79 eyelids), of which 3 patients underwent unilateral ptosis surgery due to asymmetrical ptosis. The techniques used were levator resection in 64 eyelids and frontal suspension in 15 eyelids. BPES is often clinically diagnosed. The difficulty in management lies in the complex surgery required. There is no established consensus regarding surgical techniques or the timing of the surgeries.

Occurrence of Guillain-Barr\xe9 syndrome and Myasthenia Gravis in an elderly male

IntroductionThe occurrence of both Guillain-Barré syndrome(GBS) and myasthenia gravis (MG) in the same individual is rare. The underlying pathophysiology was assumed to be autoimmune humoral mechanisms and molecular mimicry with a cross-reaction between autoantibodies and myelin sheath of peripheral nerves and acetylcholine receptors of the neuromuscular junction (NMJ).Case descriptionA 68-year-old male known diabetic and hypertensive with good drug compliance presented with acute onset quadriparesis with bulbar involvement for 1 day. On examination, he had mild neck flexion weakness and bulbar weakness. He had flaccid quadriparesis with absent deep tendon reflexes and negative Babinski. The rest of the neurological examination was normal.Discussion and evaluationBlood and electrophysiological studies showed evidence of demyelinating polyradiculoneuropathy with temporal dispersion suggestive of Guillain-Barré syndrome. He was treated with intravenous immunoglobin and complete resolution of symptoms. Two months later, he presented with new-onset asymmetrical ptosis and bulbar symptoms for 3 days. On further evaluation, repetitive nerve stimulation showed postsynaptic neuromuscular disorder pattern typical of myasthenia gravis, which was further confirmed by positive acetylcholinesterase receptor antibodies (AChR). Thymoma was ruled out by imaging. He was treated with anticholinesterases, low dose steroids, and immunosuppressants (azathioprine) following which he had improvement of symptoms.ConclusionOur patient, who was initially diagnosed with Guillain-Barré syndrome and recovered, presented 2 months later with a new-onset illness suggestive of myasthenia gravis. This existence of two different neurological entities in the same individual is a rarity, and early recognition is essential for treatment decision and prognostic strategies.

Brow Ptosis: Is Transblepharoplasty Internal Browpexy Suitable for Everyone?

Transcutaneous internal browpexy can provide patients with mild-to-moderate lateral brow ptosis, stabilization and modest lift of the lateral brow. Questions regarding effectiveness of this procedure and appropriate indications remain. The authors measured consecutive patients who underwent upper eyelid blepharoplasty with transblepharoplasty internal browpexy (TIB) September 2014 to December 2017. Pre- and postoperative brow elevation was assessed based on before and after photographs of each patient. Patient photographs were assessed for medial and lateral brow elevation, brow contouring and asymmetry. Optimal lateral brow elevation was classified as bilateral symmetrical and above the supraorbital rim for women, and symmetrical and at the supraorbital rim for men. A total of 239 patients underwent bilateral TIB and 39 underwent unilateral TIB (517 eyelids in total). Pre- and post-operative measurements were taken in 98 patients (41%), with an average elevation of the lateral brow position of 2.54 mm.Six patients had an underlying infection in the first postoperative week that resolved completely. Three patients underwent a second stage direct brow lift repair and 3 needed unrecognized ptosis repair as a second stage. Transblepharoplasty internal browpexy is an important tool that can be used in most patients with lateral and central brow ptosis, asymmetric brow ptosis and irregular contour of the brow. Additionally, browpexy adds to the success and longevity of upper blepharoplasty, while preventing early recurrence of lateral upper eyelid hooding. Patients with significant ptosis, heavy brows, medial greater than lateral ptosis, and post-facial palsy may not be good candidates for this procedure.

Ocular Weakness in Myasthenia Gravis: Changes in Affected Muscles are a Distinct Clinical Feature.

Introduction:In this study we quantitatively describe ocular weakness patterns in myasthenia gravis (MG) to help neurologists in making the clinical diagnosis and to investigate how the current outcome measures reflect ocular weakness in MG.Methods:We investigated ptosis and diplopia patterns in a retro- and prospective cohort of 306 MG patients. Diplopia was systematically examined by testing extra-ocular muscle (EOM) fatigability in two horizontal and four oblique directions for 60 seconds.Results:Of patients with initial symmetric ptosis, 40% developed asymmetric ptosis at the second visit. Changes in form of ptosis occurred less often in seronegative MG patients (50%) than in patients with acetylcholine receptor (AChR) antibodies (70%) or muscle-specific kinase (MuSK) antibodies (69%) (p = 0.038). Of patients with diplopia on the first visit, double vision contained both a vertical and horizontal component in 95%. At the second visit, 83% manifested diplopia in other gaze directions. The mean time (in seconds) to diplopia was 11.6±14.0 and the mean time to ptosis was 27.6±19.8. Diplopia or ptosis manifested within 30 seconds in 87% and 58%, respectively. Patients who manifested diplopia after 30 seconds, reported no limitations due to diplopia.Discussion:Changes in the gaze directions in which diplopia occurs or ptosis side occur frequently in MG. In diagnostically challenging cases, we recommend testing ptosis and diplopia in multiple gaze directions for 30–60 seconds during at least two follow-up visits to maximize the chance of observing changes in ocular weakness patterns.

Augmentation mammoplasty for breast volume asymmetry

The aim — to evaluate the submuscular augmentation mammoplasty long‑term results in women with relative breast volume asymmetry with identical and different size implants.Materials and methods. The study included 102 women with breast volume asymmetry, in whom the submuscular augmentation mammoplasty was performed in the period from 2012 to 2017 in the Clinic of Plastic Cosmetic Surgery. In the comparison group (n = 49), breast implants of different volume were installed, in the main group (n = 53) — the same volume calculated with developed nomogram and formula. In all cases, anatomical implants were installed. Women in both groups were representative by age, pregnancy rate, breastfeeding, absolute volumetric asymmetry of the breast (in the comparison group — 133.8 ± 3.9 ml (from 78 to 244 ml), in the main group — 134.8 ± 4.2 ml (from 79 to 206 ml), p = 0.907) and relative volumetric asymmetry of the breast (relative breast volume asymmetry) (32.2 ± 0.6 % (from 21.0 to 47.7 %) and (31.9 ± 0.7 % (from 21.4 % to 44.1 %), respectively, p = 0.925). Evaluation of the relative breast volume asymmetry was carried out in 12 — 15 months. According to previously obtained data, the value of relative breast volume asymmetry from 1.1 to 25.4 % can be considered the population norm, from 19.3 to 25.4 % — the upper limit of the norm. In the same period, the presence of such complications as caudal prosthesis migration, breast fluid ptosis, in particular asymmetric ptosis, contouring of the prosthesis were determined. The analysis of the obtained data was performed using descriptive statistics, the comparison of the mean values of the variables was carried out with the Mann — Whitney U‑test, the comparison of the shares of the variables was performed with the χ2‑Pearson test.Results and discussion. The average values of absolute breast volume asymmetry and relative breast volume asymmetry in the comparison group decreased significantly compared with the preoperative values and amounted to 76.7 ± 2.5 ml and 10.9 ± 0.3 %, all p &lt; 0.01 after the submuscular augmentation mammoplasty. The absolute breast volume asymmetry in the main group was not statistically significantly changed (130.8 ± 3.5 ml, p &lt; 0.05), while the value of relative breast volume asymmetry has significantly decreased (15.5 ± 0.3 %, p &lt; 0, 01) and was within the population norm. By mean values, the indices of absolute and relative breast volume asymmetry in the main group were statistically significantly higher compared with those in the comparison group (p &lt; 0.05). Aesthetic complications occurred in 33 (32.4 %) women: in 17 (34.7 %) in the control group and in 16 (30.2 %) in the main group: one complication in 11 (22.4 %) women in the comparison group and 12 (22.6 %) in the main group, two complications respectively in 5 (10.2 %) and 4 (7.5 %), three complications in 1 (2, 0 %) women in the comparison group (p = 0.714) in 12 — 15 months after submuscular augmentation mammoplasty. The groups did not statistically significantly differ in the incidence of complications such as caudal implant migration (p = 0.453), contour implant contouring (p = 0.638) and breast ptosis (p = 0.330), but in women in the comparison group, asymmetrical ptosis occurred with a statistically significantly higher frequency (in 8 (16.3 %) versus 1 (1.9 %) in the main group, p = 0.019). These women, despite the elimination of the volumetric asymmetry of the breast, considered the result of the operation unsatisfactory.Results and discussion. The technique of breast volume asymmetry correction with submuscular augmentation mammoplasty using identical prostheses, the volume of which is calculated according to the developed method, makes it possible to reduce the relative breast volume asymmetry value to the limits of the norm and, unlike the use of prostheses of various sizes, is associated with a statistically significantly lower frequency of breast asymmetric ptosis 2 — 3rd degree in the postoperative period.Key words: breast volume asymmetry; submuscular augmentation mammoplasty; treatment.

Paramedian Midbrain Infarction Presenting as Bilateral Asymmetric Ptosis: A Case Report and Review of Literature

Brainstem strokes can have protean ophthalmological manifestations including pupillary and extraocular muscle pareses. Incomplete paresis of oculomotor function is more common than complete paresis owing to the selective involvement of subnuclei or fascicles for various extraocular muscles. Here, we report a case of right paramedian midbrain stroke presented with asymmetric bilateral ptosis. We discuss the anatomical correlation of this presentation with the structure of oculomotor nerve nuclei and its fascicles.

Miller Fisher syndrome developing as a parainfectious manifestation of dengue fever: a case report and review of the literature

BackgroundAlthough dengue viral infections have emerged as one of the most important mosquito-borne diseases, neurological manifestations of dengue infections are uncommon. Guillain–Barré syndrome and Miller Fisher syndrome have been reported to occur as immune-mediated complications following dengue infection. We report the case of a patient who developed Miller Fisher syndrome during the acute phase of dengue fever suggesting that Miller Fisher syndrome may arise as a result of direct neurotropism of the dengue virus.Case presentationA 70-year-old Sri Lankan man with well-controlled diabetes mellitus and hypertension presented with fever of 3 days’ duration, drooping of eyelids, dysarthria, and unsteady gait. He developed bilateral asymmetric partial ptosis, complete external ophthalmoplegia, bilateral palatal palsy, unilateral tongue weakness, ataxia, and areflexia from the second day of illness. He did not have limb weakness. He had evidence of acute dengue infection including progressive thrombocytopenia and leukopenia, positive dengue non-structural protein 1 antigen, dengue immunoglobulin M antibodies, and polymerase chain reaction detection of dengue virus genome in serum. Magnetic resonance imaging of his brain and cerebrospinal fluid analysis were normal. Polymerase chain reaction for dengue virus and immunoglobulin M antibodies in cerebrospinal fluid were negative. Nerve conduction studies showed axonal neuropathy. Antibodies (immunoglobulin G, immunoglobulin M, and immunoglobulin A) against GQ1b and GT1a were negative. He was treated with intravenously administered immunoglobulins and a recommended fluid regimen for dengue fever. He made a complete recovery from dengue fever in 7 days and Miller Fisher syndrome in 20 days.ConclusionsThis case report highlights the rare occurrence of Miller Fisher syndrome during the acute phase of dengue fever. Neurological manifestations may occur as a consequence of direct neurotropism of dengue virus.

Electromyography: Beyond positive diagnosis of myastenic syndrome

Objectives Electromyography (EMG) plays a major role to confirm the presence of neuromuscular transmission disorders. Furthermore, it helps to recognize the presynaptic or postsynaptic nature of the disorder. Indeed, specialized neurophysiological tests and characteristic electrophysiological findings are widely useful for etiological diagnosis [1] , [2] . Results Here we report two cases, a 36 years-old woman and 37 years-old men who presented to our department for facial muscle weakness. The female presented for drooping of both eyelids with diplopia, which appears while reading. Neurological examination showed bilateral asymmetric ptosis and complete ophtalmoplegia. Pupillary light reflex was normal as well as the rest of the neurological examination. The neostigmine test was positive. Repetitive nerve stimulation (RNS) testat 3 Hz stimulation, showed a significant decremental response in both area and amplitude with repetitive compound muscle action potentials (R-CMAP). Muscle biopsy eliminated centro-nuclear myopathy. We then considered the diagnosis of postsynaptic congenital myasthenic syndrome. The man presented with a ten days history of facial muscle weakness, dysphonia and swallowing disorders without diurnal fluctuation. Neurological examination noted symmetric proximal limb weakness. Clinical picture was concordant with acute inflammatory demyelinating polyradiculoneuropathy. Lumbar puncture did not evidence albumino-cytologic dissociation. Electrodiagnostic studies demonstrated a reduction in the initial CMAP amplitude, a decremental response to slow stimulation rates (3 Hz), followed by incremental response after a tetanic stimulation consistant with Lambert Eaton Syndrome. Conclusion In general, full anamnestic data and careful clinical examination are sufficient to make the diagnosis of myastenic syndrome. Nevertheless, the lack of diurnal fluctuation and a clear pattern of muscle distribution can sometimes lead to misdiagnosing this disorder [2] , [3] . Moreover, myastenic syndrome with predominant facial muscle involvement share overlapping symptoms with other muscle disease like mitochondrial and centro-nuclear myopathy. These findings delineate the contribution of EMG to differential and etiologic diagnosis [1] .

Application of the Hering's law in corrective surgery for asymmetric bilateral ptosis

Objective To evaluate the clinical result of Hering's law in the correction of asymmetric bilateral ptosis. Methods From January 2014 to July 2016, 165 cases divided into 2 groups with asymmetric bilateral ptosis in mild and moderate ptosis were corrected with aponeurosis advancement type correction: A group of 15 cases, in which the surgery does not consider the influence of Hering's law, the first correction of mild side, and then corrected the heavier side; B group of 150 cases, in which the Hering's law was applied, the first correction of severe side so that the margin reached the edge of the cornea is tangent or low 0.5-1.0 mm, and then corrected mild side. That the difference of symmetry between the two sides of the palpebral fissure was less than 0.5 mm, and the follow-up was more than 3 months. The Pearson chi square test was used to compare the differences between the two groups. Results In this group, 165 cases were followed up for 3-24 months, 10 cases (66.67%) was satisfactory in group A (15 cases); 145 cases (96.67%) was satisfactory in group B (150 cases); After 3 months, all the failure cases got satisfactory result by using the Hering's law in corrective surgery again. The P value of chi square test between groups was less than 0.05. Conclusions The application of Hering's law in the correction of asymmetry bilateral ptosis is more satisfactory. Key words: Hering's law; Asymmetry bilateral ptosis; Levator palpebrae superioris muscle

Tempo(ral) was the heart of the matter

A 71-year-old woman was admitted with fever, headache, and weight loss associated with elevated inflammatory markers. She developed acute bilateral ophthalmoplegia and asymmetrical ptosis, rapidly followed by anterior ischemic optic neuropathy. Although the first temporal artery biopsy was negative, contralateral temporal artery biopsy revealed features consistent with giant cell arteritis. Even while under steroid therapy, she died a few days later from myocardial infarction. Acute bilateral complete ophthalmoplegia is a rare presentation of a limited number of possible diseases. Among these, giant cell arteritis should be suspected in the appropriate clinical scenario.

Retrospective Analysis of the Effect of Hering's Law on Outcomes of Surgical Correction of Ptosis.

IntroductionSeveral factors may influence aesthetic outcomes of ptosis surgery, especially in patients with asymmetrical ptosis. We retrospectively assessed the effect of Hering's law on surgical outcomes of patients with asymmetrical ptosis.MethodsPatients with mild to moderate asymmetrical ptosis (N = 300) who underwent advancement or plication of upper eyelid aponeurosis between January 2014 and July 2016 were enrolled. Fifty patients (group A) underwent surgery without taking into consideration the impact of Hering's law. Of these, 35 patients with unilateral ptosis (subgroup A1) underwent standard surgery on the contralateral side, whereas 15 patients with bilateral ptosis (subgroup A2) were first operated on the milder side followed by the more severely affected side.In 250 patients (group B), surgery was performed taking cognizance of the implications of Hering's law. These included 100 patients with unilateral ptosis (B1) and 150 with bilateral ptosis (B2). Difference in bilateral palpebral fissure symmetry by less than 0.5 mm was considered as satisfactory outcome.ResultsDuration of postoperative follow-up ranged from 3 to 24 months. Satisfactory outcomes were achieved over 60% of patients in group A (A1, 60.6%; A2, 66.67%) and in 96% of patients in group B (B1, 95%; B2, 96.67%). Patients with unsatisfactory outcomes underwent repair according to Hering's law after 3 months and obtained good results.ConclusionsApplication of Hering's law may improve outcomes of corrective surgery in patients with asymmetric ptosis.

Maximal levator resection in unilateral congenital ptosis with poor levator function

Background/aimsSurgical treatments for the correction of congenital ptosis with poor levator function, including frontalis suspension or maximal levator resection, remain controversial. We evaluated the postoperative surgical and cosmetic outcomes after...

Maximizing Symmetry in Upper Blepharoplasty: The Role of Microptosis Surgery.

Traditional descriptions of blepharoplasty and ptosis surgery focus on the incision and eyelid crease. However, it may be more useful to consider the tarsal platform show as the important construct in analyzing and planning aesthetic eyelid surgery. In order to measure and characterize the key contours of the eyelid, the authors find it helpful to consider the brow fat span, tarsal platform show, and margin reflex distance. Subtle eyelid ptosis can result in asymmetry by lengthening the tarsal platform show, and it is exacerbated by the tendency for the eyebrow to compensate. When ptosis is asymmetric, the plan should usually include asymmetric ptosis surgery. There are two general patterns that can be recognized and used for planning to address preoperative tarsal platform show asymmetry. If the tarsal platform show is longer on the side with worse blepharoptosis, then asymmetric or unilateral ptosis surgery will improve symmetry. In the cases of symmetric show despite asymmetric blepharoptosis, there may be bony and soft-tissue asymmetry, which leads to crowding of the orbit on the more ptotic side. Surgical planning should include consideration to increase the tarsal platform show on the more crowded side. It is not necessary to cut the eyelid skin in order to alter the tarsal show and brow fat span; ptosis surgery alone, by altering the eyelid position and eyebrow compensation, can reset the tarsal platform show/brow fat span relationship. It is important to recognize preoperative asymmetry, to predict the resetting of compensatory mechanisms, and to design asymmetric surgery, in order to maximize postoperative symmetry.