External Levator Resection Research Articles

Influence of Upper Eyelid Surgeries on Corneal Morphology Detected with Pentacam.

To analyze the corneal morphological parameters before and one month after the upper eyelid (UE) blepharoplasty and external levator resection (ELR) for ptosis surgery. Seventy eyes of 70 patients with dermatochalasis (50 eyes) and acquired aponeurotic ptosis (AAP) (20 eyes) included in this prospective study. Detailed ophthalmologic examination was performed including the best corrected visual acuity (BCVA), slit lamp examination and dilated fundoscopy. Measurements were made before and one month after the surgeries using Pentacam. Central corneal thickness (CCT), pupil center pachymetry (PCP) and thinnest pachymetry (TP), cornea front astigmatism (AST), flat keratometry (K1), steep keratometry (K2) and mean keratometry (Km) values were evaluated. Higher postoperative Km measurements were observed in dermatochalasis (p = 0.038) patients. Postoperative AST values were significantly lower in both dermatochalasis and ptosis cases (p = 0.034, p = 0.003, respectively). Increased PCP and TP were found in the AAP patients (p = 0.014, p = 0.015, respectively). UE blepharoplasty and ELR surgeries both lead to some significant changes on corneal structure post-operatively. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Revision ptosis surgery for under-correction after Müller muscle conjunctival resection

Müller muscle conjunctival resection (MMCR) may be more likely to lead to under- rather than over-correction. The choice of revision surgery is not clearly defined. MMCR patients were included if the post-operated eyelid(s) demonstrated margin reflex distance-1 (MRD1) less than 3.5mm, or if MRD1 asymmetry was greater than 0.5mm, and if they underwent subsequent revision surgery. MRD1 was the primary outcome measure and complications were secondary outcome measures. Two groups were defined: patients who underwent MMCR then repeat MMCR (M-M) and those who underwent MMCR followed by external levator resection (ELR) surgery (M-L). 18 eyelids (16 patients) were included, 12 in M-M and 6 in M-L. Mean (SD) preoperative MRD1 was 1.84mm (0.97), range -0.41 to 3.39mm. There was no difference (p=0.70) in preoperative MRD1 between M-M and M-L. In the M-M group, mean (SD) MRD1 was 1.77mm (1.12) preoperatively, 2.35mm (0.66) after the first surgery, and 3.44mm (0.31) after revision. Mean MRD1 was significantly higher after revision, compared to preoperatively (p<0.05) and after first surgery (p<0.05). In the M-L group (n=6), mean (SD) MRD1 was 1.98mm (0.90) preoperatively, 1.99mm (0.56) after the first surgery and 3.44mm (1.24) after revision. The difference between preoperative and post revision surgery MRD1 was significant (p<0.05). For patients with insufficient elevation of MRD1 or with asymmetry after MMCR, revision by MMCR or by ELR are both reasonable options.

Blepharoptosis in the Setting of an Ocular Prosthesis: A Literature Review and Description of the Novel Use of a Template Prosthesis

Blepharoptosis in acquired anophthalmia is common, yet the best treatment methods remain uncertain. We review the literature for descriptions of pathophysiology or management of blepharoptosis in acquired anophthalmic sockets and describe a technique and results of using a template prosthesis to facilitate intraoperative adjustment during external levator resection ptosis repair. The PubMed database was searched in October 2021 to identify all studies in English describing the pathophysiology or treatment of anophthalmic blepharoptosis. Seventy-one articles were identified; 13 met inclusion criteria and were reviewed. We also reviewed the charts of 12 adult patients with acquired anophthalmia undergoing external levator resection using a limbal templated, non-detailed, customshaped prosthesis. We assessed results (margin to reflex distance 1 [MRD1] and symmetry), as well as the number of eye prosthesis modifications. According to the literature, levator pathophysiology and orbital volume loss are important variables in anophthalmic ptosis. Prosthesis augmentation may be useful to treat ptosis in many instances, but may be limited by decreased motility and a poorer overall prosthesis fit. A variety of blepharoptosis repair surgical techniques have been described with reported success rates of 88–100%. The use of a template prosthesis to facilitate intraoperative lid positioning in ptosis repair was effective in 12 patients. All patients had MRD1 within 1 mm of target and with good facial symmetry. There were no complications or need for revision ptosis repair or redundancy in prosthesis fabrication at 3 years (mean; minimum 6-month) follow-up.

Efficacy and Complications of External and Internal Pediatric Blepharoptosis Repair Techniques: A Systematic Review.

To review and evaluate the efficacy and complication rates of external and internal blepharoptosis repair techniques in pediatric patients. The systematic review protocol was published on PROSPERO (CRD42020197343). Embase, MEDLINE, CENTRAL, and ClinicalTrials.gov were searched without date limitations. Two independent reviewers evaluated the articles for inclusion. Study quality and risk of bias were assessed using GRADE and Cochrane's ROBINS-I tool, respectively. Of 2,228 articles screened, 23 studies involving 730 patients were included. There were 20 case series and 3 retrospective cohort studies, but no randomized controlled studies. Overall study quality was low with serious risk of bias according to the GRADE and ROBINS-I criteria, respectively. External levator resection was the most studied procedure, evaluated in 18 studies. Seven studies investigated internal approaches including the Fasanella-Servat procedure. There was no standardized evaluation of surgical efficacy. Reoperation rates were 16.6% (range 3.6-50.9%) for external levator resection compared with 22.2% (range 0.0-25.8%) for internal approaches. The commonest postoperative complications were not sight-threatening. The most consistently reported complication was undercorrection, occurring at rates of 8.4% (range 2.4-16.7%) and 15.3% (range 2.7-75.0%) for external levator resection and internal approaches, respectively. There were no consistently applied, validated patient-reported outcomes or cosmetic outcomes. External and internal approaches have been successfully employed in pediatric blepharoptosis repair. However, noncomparative designs and risk-of-bias limit existing studies. Thus, prospectively designed studies with standardized outcome measures are required to minimize reporting bias, facilitate evidence synthesis, and support clinical decision making.

The Effect of Early Postoperative Swelling on Change in Upper Eyelid Position After External Levator Resection and Blepharoplasty.

To determine if early postoperative swelling has an effect on change in the upper eyelid position after external levator resection (ELR) or blepharoplasty. In this observational cohort study, patients >18 years old who underwent ELR or upper blepharoplasty were identified. Digital photographs in primary position were obtained at the preoperative, early postoperative week one, and late postoperative month 3 visits. Marginal reflex distance 1 (MRD1) was measured digitally. Swelling was graded on a previously validated scale from 0 to 3. Photographs were evaluated by 26 experts/professional image graders. Primary outcome measure was changed in MRD1 from preoperative to late postoperative visits. Secondary outcome measure was change in MRD1 from early to late postoperative visits. The effect of early postoperative swelling on each outcome was assessed using linear regression models. The sample contained 54 patients (25 ELR and 29 blepharoplasty). The model regressing change in MRD1 from preoperative to late postoperative visits with early postoperative swelling as the predictor was significant for ELR (R2 = 0.165, p = 0.044) but not blepharoplasty (R2 = 0.016, p = 0.515). However, the model controlling for preoperative MRD1 was not significant for ELR (B = 0.423, p = 0.354). The model regressing change in MRD1 from early to late postoperative follow up utilizing early postoperative swelling as the sole predictor was not significant for ELR (R2 = 0.010, p = 0.627) but was significant for blepharoplasty (R2 = 0.207, p = 0.013), with increased swelling associated with greater change in MRD1. Early postoperative swelling does not affect the final MRD1 outcome of ELR or upper blepharoplasty; however, blepharoplasty patients with early postoperative swelling may experience greater increase in MRD1 over follow up.

Outcomes After Müller Muscle Conjunctival Resection Versus External Levator Advancement in Severe Involutional Blepharoptosis

To compare outcomes between Müller muscle conjunctival resection (MMCR) ptosis repair and external levator resection (ELR) in patients with severe involutional blepharoptosis. Retrospective, interventional, comparative case series. A retrospective review was performed of patients who underwent ptosis repair between 2012 and 2019. Inclusion criteria were patients who underwent MMCR or ELR ptosis repair, patients with complete documentation of preoperative eyelid measurements, and patients with documentation of postoperative outcome. The main outcome measure was surgical failure, defined as patient-reported or physician-reported dissatisfaction with postoperative eyelid height or postoperative upper margin reflex distance (MRD1) of less than 2mm. Severe ptosis was described as an MRD1 of 0 or worse. Outcome analysis was also performed after stratification for concomitant blepharoplasty performed at the time of ptosis repair. A total of 231 patients (372 eyelids) met the study criteria, of which 142 eyelids had severe ptosis. Comparing outcomes of MMCR vs ELR in patients with severe ptosis, there was a statistically significant higher rate of success after MMCR (P= .0143). The rate of ptosis repair success in eyelids that underwent MMCR was 97.2% and 90.9% in patients with severe ptosis and mild/moderate ptosis, respectively (P= .42). In eyelids that underwent ELR, the rate of ptosis repair success was 77.4% and 85% in eyelids with severe ptosis and mild/moderate ptosis, respectively (P= .15). Concomitant blepharoplasty did not affect ptosis repair outcomes in any group. MMCR ptosis repair is an effective approach in treating patients with severe ptosis, and it may offer superior outcomes to ELR. In patients with good responses to phenylephrine, MMCR may offer an efficient and highly efficacious surgery regardless of presenting MRD1.

External levator resection for involutional ptosis: is intraoperative suture adjustment necessary for good outcomes?

ABSTRACT Purpose: To directly compare an algorithmic external levator resection technique with the choice of intraoperative adjustment to the same technique without intraoperative adjustments. Methods: A sequential controlled prospective comparative cohort study. Two cohorts were compared: a historical control adjustment, and an experimental non-adjustment group. Fourteen patients, 25 eyelids, were in the historical cohort; and 15 patients, 23 eyelids, were in the non-adjustment cohort. Primary acquired ptosis patients who met inclusion criteria were considered. All patients underwent a standardized external levator resection technique. Intraoperative adjustments were performed only in the historical cohort. Age, follow-up time, surgical time, and marginal reflex distance 1 (MRD1) were collected. Statistical analysis was performed using the Mann–Whitney U test. Statistical significance was p < 0.05. Primary and secondary outcome measures were postoperative MRD1 minus goal MRD1, and surgical time, respectively. Results: Twenty-five historical eyelids were compared with 23 non-adjusted eyelids. The average patient age was 68.4 years (range 19–84) and 59.3 years (range 24–83) for the adjusted and non-adjusted groups. Six-month postoperative (postoperative minus goal) MRD1 was −0.1 mm (95% CI −0.3–0.1) and −0.2 mm (95% −0.5–0.0) (p = 0.33), and surgical time was 13.8 min (95% CI 12.6–15.1) and 9.5 min (95% CI 9.0–10.1) (p < 0.001) for the adjusted and non-adjusted cohort, respectively. Conclusions: The external levator resection, utilizing a standardized algorithm approach, is an efficacious technique for involutional eyelid ptosis. With sound technique, this method can be performed without the need for intraoperative adjustment, thereby saving operative time and achieving similar results.

Results of conjunctiva-Müller muscle resection and external levator resection techniques for ptosis repair

Results of conjunctiva-Müller muscle resection and external levator resection techniques for ptosis repair

Significance of Early Postoperative Eyelid Position on Late Postoperative Result in Mueller's Muscle Conjunctival Resection and External Levator Advancement Surgery.

The purpose of this study was to determine whether advancement of the levator aponeurosis in external levator resection surgery or Mueller's muscle and conjunctiva in Mueller's muscle conjunctival resection (MMCR) surgery has a differential effect on variation in eyelid position during the postoperative period. In this retrospective observational cohort study, 2 groups of patients were defined. The first underwent MMCR surgery without tarsectomy by surgeon 1. The second underwent external levator resection without dissection posterior to the levator aponeurosis by surgeon 2. Marginal reflex distance (MRD1) was calculated based on digital photographs at baseline, 1 week postoperatively and at 3-month follow up. The primary outcome measure was change in MRD1 over time. The secondary outcome was defined as the proportion of patients with minimal early postoperative change (change of MRD1 less than 0.5 mm at 1 week postoperatively). Repeated measures analysis of variance, t test, and chi-square analyses were performed. Of the 114 eyes in the sample, there were 68 in the MMCR group and 46 in the external levator resection group. A significant interaction between group and time was noted (p < 0.05), indicating change in MRD1 over time was different between the groups. Bonferroni corrected multiple comparisons yielded significant differences between each time point for MMCR surgery (p < 0.01). No difference in MRD1 was noted for the external levator resection group from the early to late postoperative visit. Comparing each time point across groups revealed significantly lower MRD1 for the MMCR group at the early postoperative visit (p < 0.01). Preoperative and late postoperative MRD1 did not significantly differ between the groups. Regarding the secondary outcome, patients undergoing MMCR surgery were 3.7× as likely to demonstrate <0.5 mm of change in MRD1 at week 1 (p < 0.05). When considering the 39.7% (n = 27) MMCR patients in this category, 59.3% (n = 16) went on to show an MRD1 increase >1 mm from the early postoperative to the late postoperative time points. Both external levator resection and MMCR can effectively elevate the eyelid in cases of primary involutional ptosis, and have similar late postoperative results. The authors found that MMCR cases undergo greater change between the early and late postoperative period, suggesting the process of eyelid elevation after MMCR may be dynamic, involving postoperative physiologic modification.

Blepharoplasty Effect on a Described Algorithmic Approach to External Ptosis Repair: Is It Time for Unbundling?

To investigate the effects of performing a previously described algorithmic levator resection for involutional ptosis with a blepharoplasty instead of through a small incision. Eyelids with involutional ptosis and normal levator function were included in the study. An upper blepharoplasty was performed first. An external levator resection was then performed based on a described technique involving 2 mm resection of aponeurosis for 1 mm of desired lift, consistent tension on the aponeurosis between surgical cases, and standardized suture placement. Forty-one eyelids of 25 patients were included. Mean postoperative margin to reflex distance 1 (MRD1) was 2.98 mm, which was significantly higher than preoperative MRD1 (0.67 mm), but lower than the predetermined goal MRD1 (3.35 mm). Eight eyelids did not meet primary outcome of MRD1 within 1 mm of goal MRD1, with 5 undercorrections. There was no difference between the postoperative MRD1 compared with the same ptosis technique performed through a small incision only, but there were more intraoperative suture adjustments and fewer eyelids meeting the primary outcome when a concurrent blepharoplasty was performed. The addition of blepharoplasty with a previously described algorithmic approach external levator resection has an 80% success rate in achieving the primary outcome. When compared with a small-incision ptosis repair, concurrent blepharoplasty results in a less predictable outcome and an increased need for intraoperative adjustment. Performing an algorithmic technique for external levator resection with a blepharoplasty has less predictable outcomes, which raises the question of separating the procedures to improve patient care.

Blefaroptozisli Olgularda Levator Rezeksiyonu Ameliyatı Sonuçlarını Belirlemede Levator Fonksiyonunun Önemi

Objective: To compare the results of external levator resection in the upper eyelid blepharoptosis patients who have moderate and good levator function (LF). Material and Methods: This is a prospective study of 57 patients who had undergone levator resection from January 2015 to May 2016. LF was graded before surgery as moderate (5-10 mm) and good (10-15 mm) on the basis of the eyelid excursion. Preoperative and postoperative detailed information including age, gender, etiology, side, marginal reflex distance 1 (MRD1) change, operating time, cosmetic outcome and reoperations were recorded. Postoperative measurements at the 6th month visit was used for comparison. Results: The patient group consisted of 24 females (42.1%), 33 males (57.9%) with a mean age of 46.33 (range:7-79) years. Of the surgical procedures 77.1% (44/57) had good LF, 22.9% (13/57) had moderate LF. The age of the patients who had good LF was statistically significantly lower than the patients who had moderate LF (p=0.020). The operation time for the patients with good LF was statistically significantly lower than the patients who had moderate LF (p=0.001). MRD1 change and reoperation rate between two groups were not statistically significant (p>0.05). For the good LF patients, the final cosmetic outcome was statistically significantly good (p=0,012). Conclusion: For the blepharoptosis patients with good LF, the operation time is shorter and the final cosmetic outcome is better than the moderate LF blepharoptosis patients. As a conclusion, this study figured out the relevance of the preoperative assessment of LF in planning the surgical strategy for the treatment of blepharoptosis.

Biomechanics of the Levator Aponeurosis.

To investigate biomechanical properties of the levator aponeurosis. Patients undergoing external levator resection for primary or revision correction of acquired ptosis were analyzed as primary and revision groups. Immediately postoperatively, the resected segments of the levator aponeurosis were stressed by adding sequential masses to the tissue. Specimen length was recorded at each stress level. Stress-strain diagrams were used to summarize how the tissue elongated in response to the external forces, because these diagrams correct for differences in specimen size. Representative specimens were analyzed histologically. Twenty-two specimens from 14 patients in the primary group and 10 specimens from 7 patients in the revision group met inclusion criteria. In the primary group, the mean age was 66 years; 8 patients were women. In the revision group, the mean age was 69 years; 6 patients were women. Levator aponeurosis specimens in both the primary and revision group demonstrated proportional increases in length with increasing stress, demonstrating that the levator aponeurosis is extensile. Given the same amount of stress, the levator aponeurosis from primary specimens elongated more than revision specimens. Histologically, revision specimens exhibited increased collagen and haphazard, tangled elastin fibers. The levator aponeurosis obtained during surgical correction of acquired ptosis elongates in response to nominal external forces. This biomechanical property is important because the length of the aponeurosis may vary intraoperatively if variable forces are applied to the eyelid. This property might be related to connective tissue architecture and, specifically, fibrosis. Surgeons performing levator aponeurosis resection should be mindful to maintain a consistent amount of force on the levator aponeurosis when performing the resection to maximize intercase consistency.

Functional Indications for Upper Eyelid Ptosis and Blepharoplasty Surgery: A Report by the American Academy of Ophthalmology

To evaluate the functional indications and outcomes for blepharoplasty and blepharoptosis repair by assessing functional preoperative impairment and surgical results. Literature searches of the PubMed and Cochrane Library databases were conducted on July 24, 2008, with no age or date restrictions, and they were limited to articles published in English. These searches retrieved 1147 citations; 87 studies were reviewed in full text, and 13 studies met inclusion criteria and were included in the evidence analysis. The 13 studies reported the functional effects or treatment results of simulated ptosis; several types of blepharoptosis repair, including conjunctiva-Müller's muscle resection, frontalis suspension, and external levator resection; and upper eyelid blepharoplasty. Repair of blepharoptosis and upper eyelid dermatochalasis provides significant improvement in vision, peripheral vision, and quality of life activities. Preoperative indicators of improvement include margin reflex distance 1 (MRD(1)) of 2 mm or less, superior visual field loss of at least 12 degrees or 24%, down-gaze ptosis impairing reading and other close-work activities, a chin-up backward head tilt due to visual axis obscuration, symptoms of discomfort or eye strain due to droopy lids, central visual interference due to upper eyelid position, and patient self-reported functional impairment. The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Hemorrhagic ocular complications associated with the use of systemic thrombolytic agents

Objective This study aimed to report three patients with hemorrhagic ocular and orbital complications associated with the use of systemic thrombolytic agents. Design The study design was a retrospective small case series. Participants Three eyes of three patients were studied. Intervention Surgical procedures to reduce intraocular pressure or relieve optic nerve compression were performed. Main outcome measures Visual acuity and intraocular pressure were measured. Results Three patients received an intravenous thrombolytic agent on diagnosis of an acute myocardial infarction. One patient had a spontaneous suprachoroidal hemorrhage develop with secondary acute angle closure glaucoma shortly after receiving tissue plasminogen activator. Another patient had an orbital hemorrhage develop on receiving tissue plasminogen activator 4 days after an uncomplicated cataract extraction. The third patient experienced an orbital hemorrhage while receiving streptokinase 1 day after undergoing an external levator resection. Two patients suffered significant visual loss due to glaucoma or compressive optic neuropathy. Conclusions The onset of eye pain or visual loss after the administration of a systemic thrombolytic agent should alert the physician to the possibility of an ocular or adnexal hemorrhage. Prompt diagnosis and treatment can improve the likelihood of a favorable visual outcome.

Results of Blepharoptosis Surgery with Early Postoperative Adjustment

The authors reviewed 157 cases (207 eyes) of blepharoptosis corrected by external levator resection. Twenty-eight patients (29 eyelids) had unsatisfactory results. The authors adjusted 13 eyelids within 1 week of surgery. Eleven eyelids were reoperated 6 or more weeks after surgery. The mean delay between the initial and final surgery in the early group was 2.0 weeks; and, for the late group, 33.5 weeks. For those having reoperations, there was no difference in the number of procedures required to achieve satisfactory outcomes. Four patients (5 eyelids) with unsatisfactory results were offered, but declined, late repair. Early or late reoperation is effective in correcting unsatisfactory results after external levator resection. The benefits of early surgery are a reduction in time to final result, the ease with which it is performed, potential cost savings, and the opportunity one has to correct unsatisfactory results.

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.