Change In Margin Reflex Distance Research Articles

Hemorrhage Following Muller's Muscle Conjunctival Resection: Description and Case-Control Study.

The purpose of this study was to report a series of patients with postoperative hemorrhage after Muller's muscle conjunctival resection surgery and compare risk factors and outcomes with a control population. In this case-control study, records of patients who underwent Muller's muscle conjunctival resection over 5 years were reviewed for a history of postoperative hemorrhage occurring >24 hours after surgery. A 4:1 control population was matched for age and sex. Clinical data collected included demographics, medical history, medications, and subsequent surgery. Preoperative and 3-month postoperative marginal reflex distance 1 were measured digitally using ImageJ. The hemorrhage and control groups were compared using Fisher's exact tests for categorical variables and independent samples t tests for continuous variables. The hemorrhage group contained 10 patients (mean age 66.4 ± 18.5 years). The control group consisted of 40 age and sex-matched controls. Of 350 charts reviewed, there were 10 cases of postoperative hemorrhage (incidence 2.9%). Hemorrhage occurred a mean of 4.2 ± 1.3 (range 2-7) days after surgery and lasted for a mean of 29.3 ± 19.1 (range 12-72) hours. In all 10 cases, the bleeding resolved with conservative measures. There was no difference between the hemorrhage and control groups in terms of medical conditions, blood thinners, and surgical revision. Preoperative, postoperative, and change in marginal reflex distance 1 did not differ between the hemorrhage and control groups. Hemorrhage occurs approximately 4-5 days postoperatively in a small percentage of patients undergoing Muller's muscle conjunctival resection surgery. This investigation did not identify any consistent risk factors, and outcomes in this patient population appear no different than controls.

Preventing Retraction With Use of Primary Eyelid Spacer Grafts in Cosmetic Lower Lid Blepharoplasty.

Lower eyelid retraction is a challenging complication that can develop after a cosmetic lower eyelid blepharoplasty. Factors such as proptosis and negative orbital vector may place patients at a higher risk for developing postblepharoplasty retraction. Rather than addressing this complication after it occurs postoperatively, this study focuses on preventing its occurrence through the use of primary eyelid spacer grafts during the initial blepharoplasty. The goal of this study was to review the outcomes of primary eyelid spacer graft placement during the initial cosmetic lower lid blepharoplasty. A retrospective chart review was performed at Emory Eye Center between January 1, 2014, and January 1, 2022. Patients that underwent lower eyelid blepharoplasty with primary eyelid spacer graft placement were identified and included in the study. Fifteen patients with Hertel measurements of >17 and adequate preoperative and postoperative photographs were analyzed. Fifteen patients with exophthalmometry measurements of >17 and adequate preoperative and postoperative photographs were analyzed. The mean change in marginal reflex distance 2 was 0.19 mm (range, -1.05 to 1.24 mm). Two patients developed eyelid retraction at their long-term follow-up. Both patients developed retraction about 2 years after the initial surgery. Although this study was limited by its retrospective nature and had a small sample size, none of these high-risk patients developed immediate post blepharoplasty retraction. Careful preoperative evaluation should be performed to identify these high-risk patients, and placement of a primary eyelid spacer graft during the initial lower eyelid blepharoplasty should be considered in this population.

Müller Muscle-Conjunctival Resection for Treatment of Contralateral Ptosis following Unilateral External Levator Advancement.

One of the main causes of unsatisfactory outcomes after unilateral blepharoptosis surgery is asymmetry of the upper eyelid height, which occurs as a result of a contralateral eyelid droop. Therefore, the authors evaluated the efficacy of Müller muscle-conjunctival resection (MMCR) for the treatment of contralateral ptosis following unilateral external levator advancement (ELA). This study analyzed 26 eyelids of 26 patients with upper eyelid height asymmetry following unilateral ELA who underwent contralateral MMCR retrospectively. The phenylephrine test was performed before ELA and before MMCR. The main outcome measures were symmetry outcomes and clinical outcomes. The mean patient age was 55.81 ± 7.98 years (range, 44 to 70 years); 15 were female (57.7%). The Hering dependency was observed in 13 of the patients (50%) before ELA. An adequate response to phenylephrine was observed before MMCR but not before ELA. Symmetry outcomes after MMCR were perfect (<0.5 mm), good (≥0.5 mm and <1 mm), and fair (≥1 mm) in seven, 17, and two patients, respectively. An optimal upper eyelid height was noted in 47 of the 52 eyelids after the MMCR, whereas three of the 52 eyelids had minimal overcorrection, and two eyelids had undercorrection. The mean change in marginal reflex distance 1 of the contralateral eyelid droop was greater for patients with than without the Hering dependency ( P < 0.0001) after ELA but not after MMCR. Two patients (7.6%) underwent revision ELA surgery. MMCR and use of the phenylephrine test to predict the eyelid position may represent an alternative approach in patients who require management of contralateral ptosis following unilateral ELA. Therapeutic, IV.

Septum-sparing minimally invasive technique for levator advancement surgery in aponeurotic ptosis.

To evaluate the outcome of small incision levator advancement with septum-sparing technique and compare it with standard levator advancement. The surgical findings and clinical data of patients with aponeurotic ptosis who underwent small incision or standard levator advancement surgery in our clinic between 2018 and 2020 were analyzed retrospectively. For both groups; age, gender, systemic and ophthalmic comorbidities, levator function, preoperative and postoperative margin-reflex distance, change in margin-reflex distance after surgery, symmetry between the eyes, follow-up time, perioperative and postoperative complications (under/overcorrection, contour irregularity, lagophthalmos) were all evaluated and recorded. The study included 82 eyes, 46 from 31 patients in Group I who had small incision surgery, and 36 from 26 patients in Group II who had standard levator surgery. There was no statistically significant difference in surgical success between the two groups (80% and 81% respectively, p = 0.692). The levator function and preoperative margin-reflex distance correlated positively with surgical success. Small incision levator advancement is a less invasive procedure than standard levator advancement because of the smaller skin incision and preservation of orbital septum integrity, but it requires good knowledge of eyelid anatomy and experience in eyelid surgery. In patients with aponeurotic ptosis, this surgery can be performed as a safe and effective surgical technique with a similar success rate as standard levator advancement.

Long-term Results of Palpebral Fissure Transfer With No Lower Eyelid Spacer in Chronic Progressive External Ophthalmoplegia

To evaluate the long-term outcomes of the palpebral fissure transfer (PFT) technique without lower eyelid spacer in patients with chronic progressive external ophthalmoplegia (CPEO). Retrospective interventional case series. Consecutive patients with CPEO with PFT surgery (2006-2017) and a minimum follow-up of 24 months were included. The PFT included simultaneous levator resection or frontalis sling (based on the levator function and Bell's phenomenon) and lower eyelid retractor recession without spacer. Primary outcome measures included the change in margin reflex distance 1 (MRD-1), MRD-2, and palpebral fissure height (PFH) in the course of time. Potential predictors of keratopathy were also explored. There were 32 patients (64 eyelids) with the mean age and follow-up of 34.1 years (range 15-56 years) and 37.9 months (range 24-72 months), respectively. Mean MRD-1 significantly increased from -0.9 mm to 3.4 mm in postoperative weeks 1 and 2 and 1.8 mm at the last follow-up. Mean MRD-2 significantly decreased from 5.6 mm to 3.7 mm in postoperative weeks 1 and 2 and 5 mm at the last follow-up. Eyes with frank lower eyelid retraction (MRD-2 >5 mm) gained more reduction in MRD-2 compared with those with no sclera show (-0.9 mm vs -0.3 mm, P< .001). Reoperation was performed in 9 eyelids for under- (n=5) and overcorrection (n=4). Persistent keratopathy was observed in 3 eyes (4.5%). Lower eyelid retractor recession without spacer yields significant protective corneal coverage at the critical early postoperative period when the risk of keratopathy is highest.

Rapid and Sustained Eyelid Elevation in Acquired Blepharoptosis with Oxymetazoline 0.1%: Randomized Phase 3 Trial Results.

PurposeOxymetazoline 0.1% is a novel ophthalmic agent for the treatment of acquired blepharoptosis in adults that has been shown to improve upper eyelid elevation and superior visual field deficits. This analysis characterized the rapid onset of upper eyelid elevation with once-daily oxymetazoline 0.1% and durability of this effect over 42 days.Materials and MethodsPooling data from two prospective, randomized, placebo-controlled, phase 3 studies, change in marginal reflex distance 1 (MRD-1) was evaluated at a range of post-instillation time points on treatment days 1, 14, and 42. Onset of effect was assessed beginning at 5 minutes post-administration (one study) and through 6 hours at the first two visits (both studies). Overall, 203 subjects received oxymetazoline 0.1% and 101 received vehicle.ResultsOxymetazoline 0.1% demonstrated a rapid onset of action on all days evaluated. Mean changes from baseline 5 and 15 minutes post-oxymetazoline 0.1% instillation on day 1 were 0.59 ± 0.72 mm and 0.93 ± 0.81 mm, respectively (vs 0.20 ± 0.57 mm and 0.32 ± 0.64 mm with vehicle; both p<0.001). On day 14, mean changes from baseline 5 and 15 minutes post-oxymetazoline 0.1% instillation were 0.77 ± 0.85 mm and 1.11 ± 0.92 mm, respectively (vs 0.42 ± 0.78 mm and 0.41 ± 0.83 mm with vehicle; both p<0.05). This effect was also observed immediately post-instillation on day 42, where mean increases 5 and 15 minutes post-oxymetazoline 0.1% instillation were 0.86 ± 0.85 mm and 1.04 ± 0.91 mm, respectively (vs 0.42 ± 0.80 mm and 0.47 ± 0.93 mm with vehicle; both p<0.005). Significant improvements vs vehicle (p<0.001) were also observed at 2–6 hours on days 1 and 14. At all time points, the proportion of subjects showing a positive response to treatment (>0% MRD-1 increase) was >15% greater in the oxymetazoline 0.1% group (range 16.6–36.1% more responders vs vehicle), with the largest differences observed 2 and 6 hours post-instillation.ConclusionOxymetazoline 0.1% provided rapid and sustained upper eyelid elevation. Together with data demonstrating superior visual field improvement and a favorable safety profile, this analysis supports oxymetazoline 0.1% as an effective non-surgical treatment for acquired ptosis.

Mild to moderate blepharoptosis correction: Outcomes of levator aponeurosis posterior layer plication.

Conventional levator aponeurosis plication is a widely accepted technique for correction of mild to moderate ptosis. However, this method is associated with a high recurrence rate. The objective of this study was to investigate the clinical efficacy of levator aponeurosis posterior layer plication technique for correction of mild to moderate ptosis.A convenience sampling approach was used to recruit 450 patients with mild to moderate blepharoptosis at the Guangzhou Eye-Nose-Face Aesthetic Plastic Surgery Hospital between August, 2015 and December, 2017. All participants were treated with levator aponeurosis posterior layer plication technique. The primary outcome was the postoperative change in marginal reflex distance 1 (MRD1). The paired t test was used to determine the clinical efficacy. Outcomes were assessed at 1 week, 1 month, 3 months, and 6 months after surgery.The mean preoperative MRD1 was 1.7 ± 0.5 mm, and the mean postoperative MRD1 at 6-month follow-up was 3.7 ± 0.4 mm (P < .0001). According to the postoperative survey, 427 (94.9%) patients were satisfied with surgical outcomes.This modified levator aponeurosis plication technique is a simple and effective procedure for correction of mild to moderate blepharoptosis. It results in good MRD1 and high patient satisfaction.

Evaluation of the eyebrow position after external Müller's muscle tucking: A new technique for ptosis repair

Eyebrow descent commonly occurs after ptosis repair or blepharoplasty surgery. The procedures used to correct acquired blepharoptosis are primarily classified into four groups. These procedures target the levator aponeurosis, Müller's muscle, both the aponeurosis and Müller's muscle, or the frontalis muscle. In this study, we used a new technique called external Müller's muscle tucking (EMMT) on 51 patients (94 eyelids), which targets the Müller's muscle for involutional blepharoptosis. The patients were assessed by comparative analysis using pre- and post-operative digital photographs. The distances between the medial canthi, in addition to the eyebrow heights at the medial canthus, pupil and lateral canthus, were measured on a computer screen. Eyebrows descended after surgery at the medial canthus in 53 eyelids (56.4%), at the center of the pupil in 55 eyelids (58.5%) and at the lateral canthus in 48 eyelids (51.1%). The mean distances of eyebrow descent in the 94 eyelids were 0.24, 0.51 and 0.32 mm at the medial, center and lateral positions, respectively. The mean preoperative margin reflex distance (MRD) was -0.05 mm, the mean postoperative MRD was 3.79 mm and the mean change in MRD was 3.83 mm. Preoperative MRD and change in MRD were weakly associated with changes in eyebrow position in 94 eyelids. In conclusion, these findings suggest that eyebrow drooping distance is related to the preoperative severity of ptosis.

The Effect of Ptosis Surgery on Brow Position and the Utility of Preoperative Phenylephrine Testing.

Many reports have suggested that upper eyelid position and brow height can be interdependent; however, the relation is not universally observed. This study aims to understand the prevalence of this phenomenon and examine the utility of phenylephrine testing in predicting brow height change after surgery. Ptotic eyelids undergoing Muller's muscle conjunctiva resection surgery in which phenylephrine testing was performed were included. The distance from both the center of the pupil to the upper eyelid and the lower brow margin were measured in the midpupillary line. Measurements were performed based on photographs taken on presentation, after phenylephrine testing and at postsurgical follow-up. Change in eyelid margin and brow position between each of these conditions was assessed. Associations between changes in eyelid margin and brow position were analyzed, and a receiver operating characteristic curve for brow change after phenylephrine instillation as a predictor of postoperative brow change was fit. In the sample of 125 eyes, there was a significant change in mean marginal reflex distance one both with application of phenylephrine and after surgery (p < 0.05). There was no significant change in brow height with instillation of phenylephrine (p > 0.05). There was a significant change in brow height with surgery (1 mm; p < 0.05). Change in marginal reflex distance one with surgery or with phenylephrine was not significantly correlated with change in brow height after surgery (Pearson's r = 0.06; p > 0.05). Brow height change with phenylephrine was significantly correlated with brow height change after surgery (p < 0.05). Clinically relevant brow height change was defined as mean change minus one standard deviation, for a total decrease of 3.8 mm. By this criterion, 13.6% patients (n = 17) demonstrated clinically relevant brow height change. These patients had a greater preoperative brow height (p < 0.05) and a greater response to phenylephrine (p < 0.05). Based on receiver operating characteristic analysis, a threshold change of 3.5 mm in brow height with phenylephrine had a sensitivity of 0.94, and specificity of 0.10 for postoperative brow height change. Approximately 15% of the population studied tends to have a significant change in brow position with ptosis surgery. Patients who do not demonstrate a reduction in brow height of at least 3.5 mm after phenylephrine instillation preoperatively are unlikely to have clinically relevant brow height reduction after surgery.

The Role of Tissue Resection Length in the Determination of Post-Operative Eyelid Position for Muller’s Muscle-Conjunctival Resection Surgery

Purpose: To investigate the relationships between pre-operative marginal reflex distance (MRD), tissue resection length, phenylephrine response, and change in MRD with surgery for a cohort of individuals undergoing Muller’s muscle conjunctival resection (MMCR) surgery.Methods: All cases of MMCR surgery performed over a 13-year period at a single institution were screened for entry. Individuals with adequate photographic documentation and follow up were included. Patients with previous or concurrent upper eyelid, orbital or eyebrow disease of surgery were excluded. Marginal reflex distance (MRD) was calculated based on photographs utilizing public domain software. Data was plotted for inspection and appropriate statistical tests were performed.Results: During the study period 198 eyes fit criteria for analysis. A loose association between tissue resection length and change in MRD with surgery was found (r = 0.176, p < 0.05); this relationship was not significant in ANOVA analysis (p = 0.367). There was a strong association between MRD change with surgery and pre-operative MRD (r = 0.498, p < 0.01). Approximately 28% of the sample responded to 2.5% phenylephrine drop instillation with a greater than 2 mm increase in MRD. The response to phenylephrine was strongly associated with pre-operative MRD (r = −0.441, p < 0.01). A regression on change in MRD with surgery with tissue resection, phenylephrine response >2 mm and pre-operative MRD as variables revealed a model with pre-operative MRD as the only significant predictor (p < 0.01).Conclusion: Tissue resection length and phenylephrine response play small roles relative to pre-operative MRD in the determination of change in MRD with MMCR surgery.

Changes of Contralateral Eyelid Position after Unilateral Blepharoptosis Repair

Purpose: To evaluate the effect of unilateral blepharoptosis repair on contralateral eyelid position. Methods: The medical records of 39 patients who had undergone unilateral blepharoptosis repair were reviewed for preoperative and postoperative margin reflex distance (MRD). Results: Of the 39 patients, 28 (71.8%) had congenital ptosis and 11 (28.2%) revealed acquired ptosis. Twenty-two (56.4%) patients were male and 17 (43.6%) were female. Ages ranged from 3 to 55 years (mean 15.3±20.1 years). After unilateral blepharoptosis repair, the postoperative mean (±SD) change in MRD of nonoperated eye was -0.3±0.7 mm at week one, -0.3±0.6 mm at three months, and -0.2±0.7 mm at six months. Conclusions: After unilateral blepharoptosis repair, 35.9% of patients had a decrease in contralateral eyelid height at postoperative 3 months and amount of decrease was 0.2±0.7 mm.

Floppy Eyelid Syndrome: Quantifying the Effect of Horizontal Tightening on Upper Eyelid Position

To evaluate the change in upper eyelid position after horizontal surgical tightening in patients with floppy eyelid syndrome. Prospective, noncomparative, interventional case series. Eighteen patients with a clinical diagnosis of floppy eyelid syndrome. Horizontal surgical tightening of the upper eyelid was performed by full-thickness wedge resection in 24 eyelids of 18 patients with floppy eyelid syndrome. Preoperative and postoperative upper eyelid position as measured by the margin reflex distance (MRD) was assessed. Student's paired t test then was used to analyze the change in upper eyelid position after horizontal tightening alone of floppy upper eyelids. Change in upper eyelid MRD after surgery. Preoperative MRD ranged from -0.5 to 4.0 mm, with a mean of 1.9 mm (+/-1.3 mm, standard deviation [SD]). Postoperative MRD ranged from 0.5 to 6.0 mm, with a mean of 3.2 mm (+/-1.4 mm, SD). The change in MRD ranged from -0.5 to 2.5 mm, with a mean of 1.3 mm (+/-0.7 mm, SD; P<0.001). Horizontal upper eyelid tightening alone generally results in secondary improvement of the ptosis associated with floppy eyelid syndrome.

Frontalis Suspension for Upper Eyelid Ptosis: Evaluation of Different Surgical Designs and Suture Material

To compare two sling designs (single loop or double pentagon) and a variety of suture material that was used in frontalis suspension surgery for correction of upper eyelid ptosis. Retrospective, nonrandomized, comparative interventional case series. Medical record review of 99 patients (164 surgeries) who underwent frontalis suspension surgery for upper eyelid ptosis was conducted at the Jules Stein Eye Institute in 1996 to 2002. Functional and cosmetic success, margin reflex distance (MRD) and lagophthalmos were evaluated. MRD increased an average of 1.1 mm after the operation (P < .001). Ptosis recurrence was noticed in 42 cases (26%); polytetrafluoroethylene achieved the lowest recurrence rate (15%), although not statistically significant. No difference in functional success, ptosis recurrence, or change in MRD was noticed between single loop and double pentagon design. A better cosmetic outcome was noted in cases in which nylon suture was used. Complications included four cases (2.4%) of over-correction, three cases (1.8%) of suture infection (all in polytetrafluoroethylene), two cases of pyogenic granuloma (1.2%), and two cases (1.2%) of suture exposure. Frontalis suspension for upper eyelid ptosis resulted in 26% ptosis recurrence after a mean of 12 months from first surgery. Polytetrafluoroethylene showed the lowest incidence of ptosis recurrence. No statistically significant difference was found between different suture materials or loop shape that was used in the surgical technique. A better cosmetic outcome, as graded by different observers, was noted in cases in which a nylon sling was used.

Effect of Unilateral Blepharoptosis Repair on Contralateral Eyelid Position

This study evaluates the effect of unilateral blepharoptosis repair on contralateral eyelid position and assesses the relation between preoperative eyelid height interdependence, consistent with Hering law, and surgical outcome. The medical records of 54 patients (21 men, 33 women; mean age, 65 years) who underwent external levator advancement for unilateral aponeurotic blepharoptosis were reviewed for preoperative and postoperative margin reflex distance (MRD) of the nonoperated eye. To assess the relation between preoperative Hering dependence (mechanical elevation of the ptotic eyelid causing a decrease in contralateral eyelid height) and postoperative eyelid position, the change in MRD of the nonoperated eye was compared between subjects who on preoperative evaluation did (n=18) and did not (n=36) demonstrate eyelid height interdependence, using the 2-sample t test. After unilateral blepharoptosis repair, the mean (+/- SD) change in contralateral MRD was -0.2 +/- 0.8 mm. There was no significant difference in contralateral MRD change in subjects with and without preoperative Hering dependence (-0.3 +/- 0.8 mm versus -0.2 +/- 0.9 mm, respectively, p=0.78). Seventeen percent (9 of 54) of patients had a contralateral MRD decrease of more than 1 mm. Three patients (5.6%) required contralateral blepharoptosis repair within 1 year of initial surgery. After levator advancement for unilateral blepharoptosis, roughly 17% of patients will have a decrease in contralateral eyelid height of more than 1 mm, with 5% of patients requiring surgical repair during the first postoperative year. The degree of change in contralateral eyelid height cannot be reliably predicted by preoperative assessment of Hering dependence.