External Levator Advancement Research Articles

Ptosis Surgery in Patients with Myasthenia Gravis: A Useful Adjunct to Medical Therapy

ABSTRACTIntroduction: Medical management can have limitations in improving ptosis in patients with myasthenia gravis (MG). We present our experience of ptosis surgery in MG. Materials and Methods: Clinical records of all patients with MG undergoing ptosis surgery from September 2007 to November 2013 in a single center were retrospectively reviewed. Change in upper marginal reflex distance (uMRD) was the main outcome measure. Results: Sixteen external levator advancement (ELA) procedures were performed on 11 MG patients. Fourteen of 16 procedures had pre- and postoperative uMRD documented. Thirteen of 14 procedures had improved lid height; mean increase in uMRD was 2.4 mm (P=0.0005651). Two patients required secondary lid elevation. Postoperative complications included more noticeable diplopia (n=1) and exposure keratopathy (n=1). Conclusion: Ptosis surgery is a useful adjunct to medical therapy to improve lid height in MG patients with ptosis. Risks of diplopia and exposure keratopathy should be discussed with the patient pre-operatively.

Surgical treatment for medically refractory myasthenic blepharoptosis.

PurposeCurrently, only a few reports have recommended surgery as a suitable treatment for blepharoptosis associated with myasthenia gravis. The present study aims to introduce our surgical criteria, surgical options, outcomes, and precautions for medically refractory myasthenic blepharoptosis.Patients and methodsEight patients who failed to respond to at least 2 years of medical treatment and who underwent blepharoptosis surgery, from January 2008 to December 2011, were enrolled in this study. Medical records, photographs, and questionnaire results regarding postoperative status were evaluated. Of the eleven procedures performed, four involved frontal suspension, four involved external levator advancement, one involved nonincisional transconjunctival levator advancement, and two involved subbrow blepharoplasty with orbicularis oculi muscle tucking. The margin reflex distance improved postoperatively in seven patients.ResultsSeven patients had very minimal scarring, and one had minimal scarring. Five patients showed no eyelid asymmetry, one had subtle asymmetry, and two had obvious asymmetry. Seven patients were very satisfied, and one patient was satisfied with the overall result. Postoperative complications included mild lid lag with incomplete eyelid closure, prolonged scar redness, and worsened heterophoria. No patient experienced postoperative exposure keratitis or recurrent blepharoptosis during the study period.ConclusionOur results indicate that blepharoptosis surgery is effective for patients with myasthenia gravis, especially those with residual blepharoptosis despite multiple sessions of medical treatments. We recommend that neurologists and surgeons collaborate more systematically and discuss comprehensive treatment plans to increase the quality of life for patients with myasthenia gravis.

Scleral Necrosis Secondary to Nonabsorbable Suture Following Ptosis Surgery

We report a unique case of persistent scleral ulceration in a 68-year-old woman who developed eye redness, pain, and photophobia 2 days following external levator advancement with nonabsorbable suture. Slit-lamp biomicroscopy revealed an area of scleral ulceration superonasal to the limbus. The patient was treated with 6 months of topical steroids with some improvement in her condition but without complete resolution. An exposed suture or foreign body was never directly visualized; however, a mobile nodule was noted upon palpation of the eyelid. Subsequent surgical eyelid exploration revealed a retained polypropylene suture, which was dissected free and removed. Postoperatively, the area of scleral ulceration resolved completely.

Standardized Suture Placement for Mini-invasive Ptosis Surgery

To report a refinement of small-incision external levator advancement with a standardized method for suture placement for correction of acquired blepharoptosis and 1 surgeon's results with this technique. Retrospective medical record review of data from all patients with unilateral or bilateral acquired blepharoptosis who underwent small-incision external levator advancement from October 1, 2007, through January 31, 2011. Ninety-two eyelids from 66 patients with acquired blepharoptosis were treated with small-incision external levator advancement with uniform suture placement. Forty patients underwent unilateral surgery and 26 underwent bilateral surgery. The mean preoperative margin-to-reflex distance was 0.70 mm. The mean postoperative margin-to-reflex distance was 2.95 mm. Symmetry was achieved in 49 patients (74%) on the basis of a less than 1-mm difference in margin-to-reflex distance. When stratified by unilateral ptosis repair vs bilateral ptosis repair, bilateral ptosis repair achieved greater symmetry on average (81% vs 70%). Nine patients underwent revision. There were only 2 postoperative complications: one was postoperative upper eyelid bleeding and the other was exposure keratopathy. The simplified method of suture placement for small-incision external levator advancement is an effective, safe, and efficient option for acquired ptosis correction.

Blepharoptosis Repair Outcomes From Trainee Versus Experienced Staff as the Primary Surgeon

To compare outcomes of conjunctival Müllerectomy with or without tarsectomy versus external levator advancement for correction of upper blepharoptosis when performed by trainee versus staff surgeons. Retrospective, nonrandomized, interventional, consecutive case series. Charts of patients undergoing conjunctival Müllerectomy with or without tarsectomy and external levator advancement blepharoptosis repair from January 2006 through December 2009 were reviewed. Main outcome measures included age, gender, preoperative and postoperative use of artificial tears, preoperative and postoperative marginal reflex distance, surgical complications, surgeon (trainee or staff surgeon), and anesthesia time. The Student t test was used for statistical analysis. A total of 170 patients underwent 248 surgeries (154 conjunctival Müllerectomies with or without tarsectomy and 94 external levator advancements). There were 108 female and 62 male patients. Mean patient age was 62 years (range, 3 to 94 years). Forty-one (24%) patients (26 conjunctival Müllerectomies with or without tarsectomy and 15 external levator advancements) underwent concurrent eyelid surgery, such as blepharoplasty. Trainees performed surgery on a total of 88 (35%) eyelids in 60 patients (35%). There was no significant difference in the percentage of cases undergoing concomitant surgery between trainee and staff surgeons (P= .18). The mean postoperative marginal reflex distance difference was 0.53 and 0.59 for trainee and staff surgeons, respectively. Mean overall anesthesia time was 26.8minutes and 30.3minutes for trainee and staff surgeons, respectively. Complications, including increase in dry eye or irritative symptoms and reoperation, occurred in 8 (13%) of 60 patients undergoing surgery by a trainee surgeon and in 22 (20%) of 110 patients undergoing surgery by staff surgeon. There was no significant difference in eyelid symmetry (P=.55), mean anesthesia time (P= .14), complication rate (P= .26), or reoperation rate (P= .17) when surgery was performed by a trainee versus a staff surgeon. There is no significant difference in mean postoperative marginal reflex distance, mean anesthesia time, complication rate, or reoperation rate between either conjunctival Müllerectomy with or without tarsectomy or external levator advancement blepharoptosis repair performed by trainee versus staff surgeons.

The current state of ptosis repair

Posterior approach ptosis repair has made a resurgence over the last decade. The purpose of this review is to examine the history of posterior approach ptosis repair and the events that have led to its current favorable status. The evolution of the posterior and anterior approach ptosis surgeries has resulted in two favored techniques for involutional ptosis repair: the Müller muscle-conjunctiva resection (MMCR) and the external levator advancement. Each procedure has strong and prominent proponents in the oculoplastic surgery community. Recently, the MMCR has converted surgeons who have previously favored the external levator advancement. A number of factors have influenced this recent elevation of the MMCR including differing opinions on the cause of involutional ptosis, the mechanism by which the MMCR works, the predictability and speed of the MMCR, and the current reimbursements for ptosis repair by insurance companies. The recent preference for posterior approach ptosis surgery, in particular the MMCR, is multifactorial. In order to understand the evolution of opinions about the procedure, a historical knowledge of involutional ptosis and ptosis repair is necessary.

The Man Who Could Not See What He Could Not Eat

A 55-year-old Hispanic man born in New Mexico presented with progressively worsening bilateral upper eyelid ptosis and dysphagia. External levator advancement 5 years before did not improve his ptosis. A thorough systemic workup for myasthenia gravis was negative, but electromyography suggested a myopathic process. Molecular genetic testing was positive for oculopharyngeal muscular dystrophy.

Invited commentary

We congratulate Shimizu and colleagues for introducing this novel technique for the correction of blepharoptosis. 1 Shimizu Y. Nagasao T. Asou T. A new non-incisional correction method for blepharoptosis. J Plast Reconstr Aesthet Surg. 2010; 63: 2006-2014 Google Scholar The authors have hypothesised that the correction of mild to moderate blepharoptosis can be achieved with their minimally invasive technique. Principle behind this technique is almost similar to conjunctivomullerectomy where shortening of posterior lamella induces correction of mild to moderate blepharoptosis. 2 Ben Simon G.J. Lee S. Schwarcz R.M. et al. External levator advancement vs Muller’s muscle-conjunctival resection for correction of upper eyelid involutional ptosis. Am J Ophthalmol. 2005; 140: 426-432 Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar , 3 Lake S. Mohammad-Ali F.H. Khooshabeh R. Open sky Müller’s muscle–conjunctiva resection for ptosis surgery. Eye. 2003; 17: 1008-1012 Crossref PubMed Scopus (49) Google Scholar Moreover, the deep nature of the suture is also likely to re-attach the dis-inserted edge of levator aponeurosis to the upper edge of the tarsus. Because there is no incision required, the author’s technique eliminates the disadvantages of eyelid crease incision (scar and interruption of nerve supply) as well as that of conjunctival excision (dry eye). A new non-incisional correction method for blepharoptosisJournal of Plastic, Reconstructive & Aesthetic SurgeryVol. 63Issue 12PreviewThe present report introduces our correction method for blepharoptosis, in which major incisions are made on neither the skin nor the conjunctiva of the upper eyelid, and no dissection of the eyelid tissues is required. Full-Text PDF

External Levator Advancement vs Müller’s Muscle–Conjunctival Resection for Correction of Upper Eyelid Involutional Ptosis

To compare external levator advancement and Müller's muscle-conjunctival resection (conjunctivomullerectomy, or CJM) for correction of upper eyelid involutional ptosis. Retrospective, nonrandomized, comparative interventional case series. Review of medical records of 159 patients (272 surgical procedures) who underwent external levator advancement or CJM was performed. Functional and cosmetic outcome, marginal reflex distance one (MRD1), and surgical complications. A total of 159 patients (51 men, 108 women, mean age 70 years) underwent 272 surgical procedures for upper eyelid ptosis; concurrent blepharoplasty was performed in 141 cases. MRD1 increased an average of 1.6 (+/-1.5) mm, from 0.8 mm (+/-1.2) preoperatively to 2.3 mm (+/-1.2) postoperatively (P < .001). Fifteen patients (5.5%) underwent reoperation for residual ptosis, nine (18%) in the external levator advancement group, two (3%) in the CJM group, three (8%) in the external plus blepharoplasty group, and one (1%) in the CJM plus blepharoplasty group (P < .001). Patients who underwent external levator advancement had significantly more severe ptosis preoperatively but attained similar eyelid position postoperatively as compared with CJM patients. Complications included overcorrection in four cases (1.4%), lagophthalmos of 1 mm in 10 (3.6%), and pyogenic granuloma in two (<1%). External levator advancement and CJM performed alone or with concurrent blepharoplasty are effective treatments for upper eyelid ptosis. Residual ptosis or postoperative eyelid retraction occurs in up to 20% of cases and can be addressed successfully with a second operation.

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.

Blepharoptosis correction.

Blepharoptosis is a common complaint of eyelid malposition in which the upper eyelid is lower than normal. There are multiple types of blepharoptosis based on cause, and important studies have recently been published on one type, myogenic blepharoptosis. There have classically been three methods for correcting blepharoptosis. For the most severe cases, frontalis slings are often performed. New materials, such as polyester mesh, have shown promise as alternatives in forming frontalis slings. A recent paper has suggested a new algorithm for another method of blepharoptosis correction, the conjunctiva-Müller muscle resection. The effectiveness of the third type of procedure for blepharoptosis correction, the external levator advancement, has been reinforced in a study examining the procedure in cases of congenital blepharoptosis.

Ptosis associated with fatty infiltration of Müller's muscle and levator muscle.

Prominent fatty infiltration of Müller's muscle and the anterior levator muscle was noted at the time of surgery in nine of 115 patients undergoing external levator resection for ptosis. This distribution of adipose tissue was confirmed by light microscopy. Fatty infiltration appeared to be a degenerative change found in adults with congenital and acquired ptosis. Preoperatively these patients exhibited moderate to severe ptosis, fair to good levator function, and no elevation of the lid crease. The desired postoperative results were achieved with standard external levator resection and advancement techniques. The fatty appearance may lead to difficulty in identifying customary anatomical landmarks during surgery. With the exception of Horner's syndrome, abnormalities of Müller's muscle have not previously been described in association with ptosis, to these authors' knowledge.