Eyelid Contour Abnormalities Research Articles

Lateral and Medial Upper Eyelid Contour Abnormalities in Graves Orbitopathy

To determine the location of contour abnormalities in Graves upper eyelid retraction. Multiple midpupil angular eyelid distances of 75 upper eyelids of 55 patients (mean age = 41.7 ± 13.3 SD years) in the inactive phase of Graves orbitopathy were measured with a recently developed custom-made software. Sixty eyelids of 60 normal subjects were also measured as a control group. A contour peak was defined by the highest midpupil angular eyelid distance normalized (divided) by the superior limit of normality (mean + 2SD). In 45 eyelids (60%), the peaks were lateral between 120° and 150°. For high levels of retraction, the peaks tended to be centrally located with a substantial number of medial deformities (30 eyelids). Although the lateral and medial peaks were not affected by exophthalmometry, there was a statistically significant increase of medial peaks when midpupil eyelid distance was greater than 6.75 mm (χ = 5.20, p = 0.02). Lateral contour abnormalities are more frequent than medial deformities. With minor degrees of retraction, there is a predominance of lateral peaks. With higher degrees of retraction, the number of medial abnormalities is similar to the lateral ones.

Pre- and Postoperative Quantitative Analysis of Contour Abnormalities in Graves Upper Eyelid Retraction

One of the most common problems of the surgical management of Graves upper eyelid retraction is the occurrence of eyelid contour abnormalities. In the present study, the postoperative contour of a large sample of eyelids of patients with Graves orbitopathy was measured. The postoperative upper eyelid contour of 62 eyes of 43 patients with Graves orbitopathy was subjectively classified by 3 experienced surgeons in 3 categories: poor, fair, and good. The shape of the eyelid contours in each category was then measured with a recently developed custom-made software by measuring multiple midpupil eyelid distances each 15° along the palpebral fissure. The upper eyelid contour of 60 normal subjects was also quantified as a control group. The mean ratio between the sum of the lateral and medial midpupil eyelid distances (lateral/medial ratio) was 1.10 ± 0.11 standard deviation in controls and 1.15 ± 0.13 standard deviation in patients. Postoperatively, the mean midpupil eyelid distance at 90° was 4.16 ± 1.13 mm standard deviation. The distribution lateral/medial ratios of the eyelids judged as having good contours was similar to the distribution of the controls with a modal value centered on the interval between 1.0 and 1.10. The distribution of lateral/medial ratios of the eyelids judged as having poor contour was bimodal, with eyelids with low and high lateral/medial ratios. Low lateral/medial ratios occurred when there was a lateral overcorrection, giving the eyelid a flat or a medial ptosis appearance. High lateral/medial ratios were due to a central or medial overcorrection or a lateral peak maintenance. Postoperative upper eyelid contour abnormalities can be quantified by comparing the sum of multiple midpupil eyelid distances of the lateral and medial sectors of the eyelid. Low and high lateral/medial ratios are anomalous and judged as unpleasant.

Relationship between Immediate Post-Operative Appearance and 6-Week Operative Outcome in Trichiasis Surgery

BackgroundSurgical technique, including suture placement and tension, is believed to contribute to the outcome of bilamellar tarsal rotation surgery for trachomatous trichiasis. However, the immediate post-operative appearance that minimizes the chance of recurrence and other adverse outcomes has not been investigated.Methodology/Principal FindingsTo explore whether the degree of correction immediately after surgery is predictive of surgical outcome at the 6-week post-operative visit, photographs taken immediately after surgery were used to predict surgical outcomes, including the severity of eyelid contour abnormality and trichiasis recurrence. Both eyelid contour abnormalities and recurrence were accurately predicted from the immediate post-operative photographs by an experienced oculoplastic surgeon 85% and 70% of the time, respectively. Participants with a “slight over-correction” that resulted in no eyelid contour abnormality and no recurrence were used to identify immediate post-operative contours that lead to a successful surgical outcome.Conclusions/SignificanceThe immediate post-operative eyelid contour is an important indicator of post-operative success of BLTR surgery. Based upon our findings, we developed a Surgery Photocard. This card illustrates some examples of immediate post-surgical appearances, which led to a successful outcome, as well as sub-optimal appearances, which led to poor surgical outcomes. The card also provides suggestions for improving the appearance by adjusting the suture placement or tension based upon standard oculoplastic principles.

Definitions and Standardization of a New Grading Scheme for Eyelid Contour Abnormalities after Trichiasis Surgery

BackgroundClear definitions of outcomes following trichiasis surgery are critical for planning program evaluations and for identifying ways to improve trichiasis surgery. Eyelid contour abnormality is an important adverse outcome of surgery; however, no standard method has been described to categorize eyelid contour abnormalities.Methodology/Principal FindingsA classification system for eyelid contour abnormalities following surgery for trachomatous trichiasis was developed. To determine whether the grading was reproducible using the classification system, six-week postoperative photographs were reviewed by two senior graders to characterize severity of contour abnormalities. Sample photographs defining each contour abnormality category were compiled and used to train four new graders. All six graders independently graded a Standardization Set of 75 eyelids, which included a roughly equal distribution across the severity scale, and weighted kappa scores were calculated. Two hundred forty six-week postoperative photographs from an ongoing clinical trial were randomly selected for evaluating agreement across graders. Two months after initial grading, one grader regraded a subset of the 240 photographs to measure longer-term intra-observer agreement. The weighted kappa for agreement between the two senior graders was 0.80 (95% CI: 0.71–0.89). Among the Standardization Set, agreement between the senior graders and the 4 new graders showed weighted kappa scores ranging from 0.60–0.80. Among 240 eyes comprising the clinical trial dataset, agreement ranged from weighted kappa 0.70–0.71. Longer-term intra-observer agreement was weighted kappa 0.86 (95% CI: 0.80–0.92).Conclusions/SignificanceThe standard eyelid contour grading system we developed reproducibly delineates differing levels of contour abnormality. This grading system could be useful both for helping to evaluate trichiasis surgery outcomes in clinical trials and for evaluating trichiasis surgery programs.

Rates and Risk Factors for Unfavorable Outcomes 6 Weeks after Trichiasis Surgery

Several studies of trichiasis recurrence suggest an association between surgical factors and long-term recurrence, yet data on short-term risk factors are limited. This study was conducted to evaluate risk factors for early trichiasis recurrence and other unfavorable short-term outcomes. Trichiasis patients presenting for surgery were evaluated for presence of active trachoma and signs of cicatricial outcomes of trachoma, including number of trichiatic lashes, epilation, and entropion. Surgical factors recorded included incision length, surgery duration, and the surgeon performing the operation. Participants were followed up for 6 weeks after surgery and evaluated for eyelid closure defect and trichiasis recurrence; in addition, in two thirds of the patients, eyelid contour abnormality and granuloma formation were evaluated. First-time trichiasis surgery was performed on 2615 eyelids. Of these, 2601 eyelids without surgical failure were followed up 6 weeks after surgery. Of the eyelids treated, 2.3% had recurrent trichiasis and 1.3% had an eyelid closure defect. Data on eyelid contour abnormalities and granuloma formation were recorded for 1881 eyes, with rates of 1.2% and 10.5%, respectively. Associated risk factors differed by outcome. Surgeon was predictive of eyelid closure defect and granuloma formation. Eyelids with short incisions were nearly four times more likely to have recurrent trichiasis (95% confidence interval, 1.7-9.3). Baseline trichiasis severity was predictive of eyelid contour abnormalities and recurrent trichiasis. Epilation was associated with granuloma formation, but was protective against eyelid closure defect. Surgical factors are important predictors of unfavorable outcomes in the weeks immediately after surgery. Although the overall rate of serious uncorrectable unfavorable outcomes was very low, the high rate of granuloma formation, which can be treated by removal, highlights the need for follow-up of patients after trichiasis surgery. (ClinicalTrials.gov number, NCT00347776.).

Horizontal Eyelid Tightening for the Correction of Eyelid Contour Abnormalities After Ptosis Repair

Eyelid contour abnormalities after ptosis surgery can be a challenge to manage. The authors present a method of surgically correcting such abnormalities via horizontal eyelid tightening.

Fasanella—Servat procedure: indications, efficacy, and complications

Background: The Fasanella-Servat procedure is used for the repair of mild to moderate ptosis. The purpose of this study was to determine the efficacy of the Fasanella-Servat procedure for the repair of several forms of ptosis. Methods: The authors retrospectively reviewed 169 charts of 2 surgeons from 1988 to 1996. All patients had undergone a Fasanella-Servat procedure for ptosis. Patients with less than a 1-month follow-up were excluded, leaving 153 eyelids of 144 patients. Surgical success was defined as lid symmetry within 0.5 mm or correction of eyelid contour abnormality from previous surgery or trauma. Results: Ptosis was classified as involutional, occurring after intraocular surgery, congenital, due to Horner's syndrome present after levator surgery, and myogenic/other.With a mean follow-up of 7 months, success was achieved in 89.5% of cases (137/153). Among subgroups, success was highest at 100% in Horner's syndrome (8/8) and post-levator surgery (11/11), and lowest in congenital ptosis at 76.4% (13/18). Postoperative problems included dry eye symptoms (6/144 patients), contour abnormalities in 12 lids, and dermatochalasis in 10 lids. Interpretation: The Fasanella-Servat operation is effective for mild to moderate ptosis from a variety of causes and for contour abnormality correction in patients with little or no ptosis. Despite the long-held belief that excision of the accessory lacrimal glands of Wolfring leads to dry eye symptoms, our study found this to be the exception. This procedure has the advantage of high reliability when reasonable preoperative criteria are applied and is minimally invasive.

Correction of congenital ptosis using Ptose‐up

Abstract Purpose: To determine the functional and cosmetic results of Ptose‐up ptosis sling material for the correction of congenital ptosis. Methods: In this prospective study, 13 frontalis sling suspension surgeries were performed by the same surgeon in 12 consecutive children with congenital ptosis. The sling material was sutured to the tarsus through an eyelid crease incision. The eyelid contour, complications during and following surgery were recorded. Results: The ages of the cases ranged from 1 to 21 years (mean 7.5 ± 6.9 years). The patients were followed‐up for at least 6 months (mean 16.7 ± 8.4 months). All ptotic eyelids were corrected with acceptable final lid position. Exposure keratitis, wound infection, eyelid contour abnormality or overcorrection was not observed in any patient. One case had trauma to the periorbital area one month following surgery which resulted in recurrent ptosis and required re‐operation. Another patient with recurrent ptosis at presentation had persistent eyelash ptosis following surgery which required an additional surgery. Good to excellent final postoperative height was achieved in 8 patients (9 eyelids), and 2 cases with mental retardation could achieve good height with conscious active brow elevation. Conclusions: Ptose‐up sling material is a biocompatible, biointegrable, inert material, which results in cosmetically and functionally satisfactory results following surgery of congenital ptosis. Following surgery, patients learn to use their frontalis muscle to achieve satisfactory eyelid height. This can also be achieved in patients with mental retardation if taught to exert conscious effort to activate the frontalis muscle.

Transcutaneous Lower Eyelid Blepharoplasty With Fat Excision

To prove through our experience that the use of transcutaneous lower eyelid blepharoplasty results in negligible incidence of unacceptable scar and eyelid malposition and that the overall lower eyelid contour is acceptable. A detailed overview of the lower eyelid anatomy and a discussion of the "aging" eyelid are further discussed. Retrospective, observational study. The study population comprised 50 patients (100 eyes) seen at the McCollough Plastic Surgery Clinic, Gulf Shores, Ala, between 2002 and 2003 (45 women and 5 men), who had undergone transcutaneous lower eyelid blepharoplasty with fat excision. Lower eyelid blepharoplasty was performed by the senior surgeon (E.G.M.), and the surgical technique was identical in all cases. The patients were followed up for a minimum of 6 months and a maximum of 2 years. Patients were selected on the basis of return visits to record the findings, documented by consecutive digital photos. By comparing standard blepharoplasty digital views, the patients were assessed by 3 independent unbiased plastic surgeons. This study was performed in a private practice setting. The main outcome measure was mean score for the presence of unacceptable scarring, the presence of lower eyelid malposition, and the overall appearance of the eyelid after transcutaneous lower eyelid blepharoplasty, as assessed with the Garcia-McCollough Scale for Lower Eyelid Appearance. The 50 patients were retrospectively reviewed and analyzed by a group of 3 unbiased plastic surgeons, and there was negligible evidence of lower eyelid contour abnormality, lower eyelid malposition, or easily visible scars. Transcutaneous lower eyelid blepharoplasty with fat excision is a time-tested method of correcting the undesirable sequelae of the aging eye. This technique not only is a safe and effective manner to rejuvenate the lower eyelid but also results in virtually nonexistent ill effects.

Autologous Pedal Extensor Tendon for Frontalis Suspension in the Correction of Blepharoptosis with Poor Levator Function

Introduction: Blepharoptosis with poor levator function is commonly repaired with a frontalis suspension procedure. A variety of suspension materials have been used, including autologous fascia lata, banked fascia lata, Supramid, Gortex, silicone, and Mersilene. Autologous materials offer the advantage of less rejection and granuloma formation, and lower rates of ptosis recurrence. Autologous fascia lata, although commonly used, has been associated with hemorrhage, scar problems, pain, and muscle herniation over the harvest site. Additionally, sufficiently long autogenous fascia is sometimes not readily available. We describe the use of autologous pedal extensor (extensor digitorum longus) tendon for frontalis suspension. Materials and Methods: In a retrospective study, the authors evaluate 19 frontalis sling suspension surgeries using pedal extensor tendon in 17 consecutive patients with ptosis with poor levator function. The method of harvesting the pedal extensor tendon is described in detail. Results: Of 19 ptotic eyelids, 18 were successfully corrected with good final lid position. One eyelid was undercorrected. No recurrence of ptosis was encountered. No wound infection, eyelid contour abnormality, or ptosis overcorrection occurred. One eye developed exposure keratopathy that resolved with conservative treatment. There were no major complications associated with the pedal extensor tendon donor site. Discussion: Frontalis suspension with an autogenous pedal extensor tendon appears to be cosmetically sound and an effective treatment for ptosis with poor levator function. Its use as an alternative material to fascia lata for frontalis sling surgery can be considered.

Long-term results of frontalis suspension using autogenous fascia lata for congenital ptosis in children under 3 years of age

Purpose To evaluate the outcome of frontalis suspension surgery for congenital ptosis using autogenous fascia lata for children under 3 years of age. Design Retrospective nonrandomized interventional case series. Methods This study included nine children (14 eyelids) with severe congenital ptosis aged less than 3 years. All patients underwent frontalis suspension surgery using autogenous fascia lata. Postoperative lid level results, ptosis recurrence, and cosmetic appearance of leg scars were evaluated after the operation. Results The mean age of the patients was 15.3 months (range, 6 months to 2.5 years) with a mean follow-up period of 41.6 months (range, 18 to 96 months). All children achieved satisfactory cosmetic and functional results, with no postoperative complications such as wound infection, corneal exposure, eyelid contour abnormalities, or ptosis overcorrection. No recurrence of ptosis was encountered. Harvesting was not difficult, and a sufficient amount of material was achieved. There was one patient (11.1%) with a hypertrophied leg scar. Conclusions Frontalis suspension using autogenous fascia is proposed as a possible procedure for correcting congenital ptosis in children younger than 3 years of age. It appears to be an effective and feasible treatment for children with poor levator muscle function in this age group.

Autogenous palmaris longus tendon as frontalis suspension material for ptosis correction in children

Purpose: To determine the safety and efficacy of autogenous palmaris longus tendon as a sling material in frontalis suspension surgery for ptosis correction in children. Methods: In a prospective study, the authors evaluated 15 frontalis sling suspension surgeries using palmaris longus tendon in 14 consecutive children with congenital ptosis. The method of harvesting the palmaris longus tendon is described in detail. Results: The mean age of the patients was 4.7 years (range, 2 to 7 years). At a mean follow-up of 30 months (range, 20 to 40 months), all ptotic eyelids were successfully corrected with good final lid position. No recurrence of ptosis was encountered. In one eye, knot slippage of the sling was related to upper eyelid trauma, which was readily repaired. Otherwise, no exposure keratitis, wound infection, eyelid contour abnormality, or ptosis overcorrection occurred. There were no complications associated with the palmaris longus tendon donor site. Conclusion: Frontalis suspension with autogenous palmaris longus tendon appears to be an effective treatment for congenital ptosis with poor levator function in children. Its use as an alternative material to fascia lata for sling surgery in children can be considered.

Internal Vertical Shortening for the Correction of Diffuse or Segmental Postoperative Blepharoptosis

In a series of 18 patients operated on because of postoperative eyelid contour abnormalities or small to moderate amounts of diffuse blepharoptosis, a technique of internal vertical shortening produced consistently reliable results. A cosmetically acceptable result was achieved in 17 of 18 patients (95%); only one of 18 (5%) showed no improvement. In cases of overcorrected upper eyelid retraction secondary to thyroid ophthalmopathy, 11 of 11 patients had cosmetically acceptable results. In those with blepharoptosis or eyelid contour abnormalities secondary to other causes, six of seven patients (84%) had cosmetically acceptable results. In our technique of internal vertical shortening, a predetermined amount of conjunctiva and overlying scar tissue or levator aponeurosis is removed. The resection uses a posterior approach to remove tissue from the superior tarsal border upward.

Anterior Tarsectomy Reoperation for Upper Eyelid Blepharoptosis or Contour Abnormalities

In five cases, a simplified anterior tarsal resection corrected complicated upper eyelid blepharoptosis and contour abnormalities. One case of residual blepharoptosis after levator muscle resection was corrected by resecting an amount of tarsus equal to the desired amount of correction. Two cases of upper eyelid blepharoptosis resulting from overcorrected levator muscle recession were corrected in the same manner. In one case of residual segmental blepharoptosis of the upper eyelid causing a contour abnormality, we resected a segment of tarsus corresponding to the amount of blepharoptosis in the affected segment of the eyelid. In one patient who developed a contour abnormality after a Fasanella procedure with segmental blepharoptosis nasally and overcorrection temporally, a segment of tarsus resected nasally and inserted temporally created an even contour. Anterior tarsal resection is a simple method of revising the upper eyelid level of contour in situations where the upper eyelid anatomy has been distorted by previous surgery.

Correction of Upper Eyelid Retraction

We used two surgical procedures to treat upper eyelid retraction in ten patients: either a posterior myectomy or the anterior levator muscle recession technique. Our choice was usually based on the amount of retraction. We used the posterior myectomy technique to treat up to 2 mm of retraction or localized retractions (five cases), particularly after blepharoptosis surgery. We used the anterior recession method to treat more than 2mm of retraction (five cases), particularly when associated with dysthyroid ocular disease. Complex eyelid contour abnormalities were treated with a combined recession-resection approach to the aponeurosis of the levator palpebrae superioris muscle (one case).