Eyelid Elevation Research Articles

Clinical Outcomes of Conjunctiva-Müller Muscle Resection

The aim of this study was to investigate the clinical outcomes of conjunctiva-Müller muscle resection (CMMR) in patients with mild to moderate ptosis, the factors related to successful procedures, and the influence of CMMR on dry eye symptoms and signs. In a tertiary university hospital, the medical records of 30 patients who had CMMR were retrospectively reviewed, including the detailed preoperative and postoperative eyelid measurements, surgical outcomes, and dry eye evaluations. Inclusion criteria included older than 18 years, acquired ptosis, and no previous eyelid surgery or trauma. The surgery had a success rate of 86.7%. In the patients who responded to phenylephrine application with a marginal reflex distance 1 (MRD1) increase of more than 2 mm, the postoperative MRD1 correction was 2.41 ± 0.84 mm, whereas the postoperative MRD1 correction was 1.19 ± 0.78 mm in the group with responses of less than 2 mm. The postoperative MRD1 correction was 1.21 ± 0.80 mm in the group with a negative response. Seven patients complained of dry eye symptoms and showed a transiently significant aggravation in the Schirmer test and ocular surface disease index score after the procedure, which normalized within 2 months postoperatively. Responsiveness to phenylephrine is directly correlated with the postoperative results. Nevertheless, even in the patients with negative phenylephrine response, some degree of eyelid elevation can be expected. Damage to goblet cells after the procedure may result in defective tear production, leading to transient aggravation of dry eye symptoms.

Ten Years’ Experience with Unilateral Conjunctival Mullerectomy in the Asian Eyelid

The purpose of this study was to report 10 years of experience with unilateral conjunctival mullerectomy in the Asian eyelid. Medical records of patients with unilateral ptosis who underwent conjunctival mullerectomy performed by a single surgeon from January of 2001 to December of 2011 were reviewed. The following factors were investigated: preoperative marginal reflex distance-1 of the ptotic and contralateral normal eyelids, levator function, and preoperative marginal reflex distance-1 after instillation of 2.5% phenylephrine of the ptotic eye. Main outcome measures were the surgical success rate of conjunctival mullerectomy, comparison of preoperative factors according to surgical results, and the results of univariate and multiple logistic regression analyses to identify the factors associated with undercorrection of conjunctival mullerectomy. Of a total of 64 eyes (64 patients), 53 eyes (82.8 percent) showed surgical success, two eyes (3.1 percent) showed overcorrection, and nine eyes (14.1 percent) showed undercorrection. The mean preoperative marginal reflex distance-1 difference between both eyes was 2.20 mm in the undercorrection group and 1.40 mm in the surgical success group (p = 0.001). The percentage of patients in whom the phenylephrine test did not raise the lid up to the height of the nonptotic eyelid was 88.9 percent (eight of nine eyes) in the undercorrection group, and 28.3 percent (15 of 53 eyes) and 0 percent (zero of two eyes) in the surgical success and overcorrection groups, respectively (p = 0.001). Multiple logistic regression analysis showed that patients in whom the phenylephrine test did not raise the lid up to the height of the nonptotic eyelid were associated with an increased risk of undercorrection after conjunctival mullerectomy (OR, 10.740; 95 percent confidence interval, 1.098 to 15.431; p = 0.041). We observed 0.18 ± 0.08-mm lid elevation per 1 mm of conjunctival mullerectomy. Conjunctival mullerectomy can be successfully performed to correct unilateral ptosis in the Asian eyelid in 82.8 percent of patients. Patients with greater degrees of preoperative ptosis and those in whom the phenylephrine test did not raise the lid up to the height of the nonptotic eyelid have a higher possibility of undercorrection. Therapeutic, IV.

Frontalis muscle flap as sling in severe ptosis

Aim: Evaluation of the effect of frontalis muscle flap as sling surgery in severe ptosis with poor levator palpebral superioris (LPS) action.Method: Twenty-five eyes of 18 patients with severe congenital ptosis with poor LPS action were studied over a period of two years. It comprised of 13 eyes of 13 patients of severe unilateral congenital ptosis and ten eyes of five patients with ptosis associated with blepharophimosis syndrome. All patients underwent frontalis muscle flap sling surgery and were followed for six months.Result: At final follow up, 88% of patients had a satisfactory result. No patients required re-surgery. Lagophthalmos was the most common complication seen which subsided by six months. The surgical lid elevation was effective without any recurrence or complete failure.Conclusion: Frontalis muscle flap sling surgery is an effective procedure for severe ptosis with poor LPS action.

The Minimally Invasive, Orbicularis-Sparing, Lower Eyelid Recession for Mild to Moderate Lower Eyelid Retraction With Reduced Orbicularis Strength

IMPORTANCE Identifying a procedure to address lower eyelid retraction (LER) in the presence of an orbicularis deficit is a useful tool for aesthetic and reconstructive eyelid surgery. OBJECTIVE To describe and evaluate a surgical technique consisting of a closed canthal suspension and true lower eyelid retractor recession to address LER in the setting of orbicularis weakness. DESIGN, SETTING, AND PARTICIPANTS A retrospective medical record review of patients who underwent the minimally invasive, orbicularis-sparing, lower eyelid recession from January 1, 2010, to October 1, 2012, by one of us (G.G.M.) in an ophthalmic plastic surgical practice. We included 29 patients with reduced orbicularis strength and LER resulting from eyelid paresis related to facial nerve disease, surgical trauma (after blepharoplasty), involutional change, or idiopathic causes. INTERVENTIONS Surgical intervention consisting of closed canthal suspension and lower eyelid retractor recession. MAIN OUTCOMES AND MEASURES Surgical results, complications, and patient satisfaction. RESULTS The 29 patients included 18 women and 11 men. The mean patient age was 52 (range, 6-72) years; mean follow-up, 11 (range, 6-21) months; and mean preoperative orbicularis strength, 2.7 (on a scale of 0-4, where 0 indicates no function and 4, normal function). The causes of orbicularis weakness included eyelid paresis related to facial nerve disease (11 patients), surgical trauma (13 patients), involutional change (4 patients), and an isolated idiopathic finding (1 patient). In 12 patients, the eyelid retraction was unilateral; in 17, bilateral. A small tarsorrhaphy was added to the surgery in 6 patients with facial nerve disease. The mean eyelid elevation after surgery was 1.80 mm, with only minor complications. Patient and surgeon satisfaction were high. CONCLUSIONS AND RELEVANCE Recent publications have demonstrated the utility of closed canthal suspension and true lower eyelid retractor recession as separate procedures. In the setting of LER with reduced orbicularis strength and/or tone, the techniques can be combined to recess the lower eyelid without disturbing the already compromised lower orbicularis muscle (minimally invasive, orbicularis-sparing, lower eyelid recession). The combination technique is safe and effective and yields excellent results. LEVEL OF EVIDENCE 4.

Evaluation of Safety and Efficacy of Silicone Rod in Tarsofrontalis Sling Surgery for Severe Congenital Ptosis

To evaluate the efficacy and safety of silicone rod in tarsofrontalis sling surgery for severe congenital ptosis. A prospective, case series study was performed in 46 patients (56 eyelids) who underwent tarsofrontalis sling surgery using silicone rod for severe congenital ptosis. The efficacy of the silicone rod in tarsofrontalis sling surgery was evaluated by marginal reflex distance1 (MRD1), postoperative eyelid symmetry, and recurrence of ptosis. Safety of silicone rod was assessed by noting postoperative complications. The postoperative results were considered as good if MRD1 was 4.0 ± 0.5 mm (3.5-4.5 mm) and symmetry ≤1 mm; fair if MRD1 was 2.5 ± 0.5 mm (2-3 mm) and symmetry 1.5 to 2.0 mm; and poor if MRD1 was <2.0 mm and symmetry <2.0 mm. In cases of unilateral congenital ptosis, good results were seen in 83.3% cases, fair results in 11.1% cases, and poor results in 5.5% cases. In cases of bilateral congenital ptosis, good results were seen in 80.0% cases, fair in 15.0% cases, and poor result in 5.0% cases. Satisfactory postoperative eyelid elevation of ≥2 mm was seen in 93% cases. Complications in the form of granuloma formation, subsequent silicone rod extrusion, and recurrence occurred in 4% cases. The use of silicone rod in tarsofrontalis sling surgery for severe congenital ptosis repair is a safe and effective surgery, with few complications and easy removal and adjustment.

Apraxia of eyelid opening after brain injury: a case report.

Apraxia of eyelid opening (AEO) is a syndrome characterized by the patient's difficulty in initiating eyelid elevation spontaneously. Most of the reported cases were associated with extrapyramidal diseases. We report a case of AEO presented after traumatic brain injury, not with extrapyramidal diseases, and improved by dopaminergic treatment. A 49-year-old man underwent a traffic accident and was transferred to the emergency room in an unconscious state. Brain computed tomography (CT) revealed a subdural and epidural hemorrhage at right temporal and bilateral frontal lobes, and he received burr-hole trephination. After receiving comprehensive treatment including occupational therapy, cognition and mobility gradually improved, but he could not open his eyes voluntarily. With dopaminergic treatment (levodopa/benserazide 200/50 mg), he started to open his eyes spontaneously, especially when eating and undergoing physical training. This case showed that AEO may occur after brain injury and that dopaminergic treatment is beneficial also in AEO patients without extrapyramidal diseases.

Levator resection in the management of myopathic ptosis.

PurposeTo evaluate the results of levator resection in patients with myopathic ptosis.MethodsThe medical records of consecutive patients who underwent levator resection surgery performed for myopathic ptosis between October 2009 and March 2013 were reviewed. Indications for surgery were ptosis obscuring the visual axis and margin-reflex distance ≤2 mm. Surgical success was defined as clear pupillary axis when the patient voluntarily opened his eye and margin-reflex distance ≥3 mm. We analyzed the effect of levator function and Bell's phenomenon on the rates of success and corneal complication.ResultsThis series included six male and six female patients. Levator function was between 4 and 12 mm. We performed bilateral levator resection surgery in all patients. The mean follow-up time was 14.8 months (range, 6 to 36 months). No patient was overcorrected. Adequate lid elevation was achieved after the operation in 20 eyes. Ptosis recurred in three out of 20 eyes after adequate lid elevation was achieved. Our overall success rate was 70.8%. In three eyes with poor Bell's phenomenon, corneal irritation and punctate epitheliopathy that required artificial eye drops and ointments developed in the early postoperative period, although symptoms resolved completely within 2 months of the resection surgery. No patients required levator recession or any other revision surgery for lagophthalmos or corneal exposure after levator resection.ConclusionsLevator resection seems to be a safe and effective procedure in myopathic patients with moderate or good Bell's phenomenon and levator function greater than 5 mm.

Genetic diseases affecting the eyelids

The molecular basis of a number of inherited diseases that affect the eyelids has been elucidated over the last two decades. Due to the vast number of these diseases, a clinician may become overwhelmed by the volume of data, making it difficult to incorporate newer information into his or her clinical practice. This article intends to review the recent developments of inherited diseases that affect the eyelids that a typical oculoplastic surgeon will encounter. This review proposes categorizing genetic diseases affecting the eyelids on rarity and whether the disease manifests itself at birth or later in life. Based on this classification system the following 10 diseases (the first five manifesting at birth, the last five later in life) are considered more likely to be encountered by the typical oculoplastic surgeon and reviewed in detail: blepharophimosis-ptosis-epicanthus inversus syndrome, congenital fibrosis of the extraocular muscles, lymphedema-distichiasis syndrome, neurofibromatosis type 1, congenital myasthenic syndrome, oculopharyngeal muscular dystrophy, chronic progressive external ophthalmoplegia, myotonic dystrophy, neurofibromatosis type 2, and basal cell nevus syndrome. The remaining known genetic disorders that affect the eyelids are considered less likely to be encountered by the typical oculoplastic surgeon and are listed in tabular form. It is prudent for the oculoplastic surgeon to be knowledgeable of inherited disorders that affect the eyelids to aid in accurate diagnosis, counseling, and treatment. The development of future therapies may at some point make treatment of these diseases no longer surgical. http://links.lww.com/COOP/A4.

Alternative Surgical Treatment of Paralytic Lagophthalmos Using Autogenic Cartilage Grafts and Canthopexy

This study aims to analyze the use of autogenic auricular cartilage grafts as weight for the upper eyelid in conjunction with lateral canthopexy for patients with mild paralytic lagophthalmos. This procedure was also accompanied by elevation of the lower eyelid using the cartilage graft for moderate cases. We conducted a retrospective study including case series of 30 patients with paralytic lagophthalmos from 1997 to 2010. For mild cases, cartilage from the auricular scapha was placed in pretarsal space of the upper eyelid and cartilage from the concha was inserted in preaponeurotic space and then sutured to the levator aponeurosis in conjunction with lateral canthopexy. For moderate cases, lower eyelid was also elevated by suturing cartilage graft to tarsum and resting it by the inferior orbital rim. All patients had some degree of keratopathy before the intervention. After treatment, they presented with evident clinical improvement, reduction of eye symptoms, and resolution of keratopathy. During the mean postoperative follow-up of 37.3 months, none of the patients presented with cartilage graft exposition, reabsorption, visibility, infection, or warping. Complete eye closure was achieved in 24 (80%) patients, whereas the remaining 6 (20%) patients had residual asymptomatic lagophthalmos. The intervention using autogenic auricular cartilage grafts explained in this study was only effective for the treatment of mild and moderate cases of paralytic lagophthalmos. This outpatient surgery is associated with low morbidity and achievement of functional and aesthetic improvement.

Atrophy, Fibrosis, and Increased PAX7-Positive Cells in Pharyngeal Muscles of Oculopharyngeal Muscular Dystrophy Patients

Oculopharyngeal muscular dystrophy (OPMD) is a late-onset autosomal dominant inherited dystrophy caused by an abnormal trinucleotide repeat expansion in the poly(A)-binding-protein-nuclear 1 (PABPN1) gene. Primary muscular targets of OPMD are the eyelid elevator and pharyngeal muscles, including the cricopharyngeal muscle (CPM), the progressive involution of which leads to ptosis and dysphagia, respectively. To understand the consequences of PABPN1 polyalanine expansion in OPMD, we studied muscle biopsies from 14 OPMD patients, 3 inclusion body myositis patients, and 9 healthy controls. In OPMD patient CPM (n = 6), there were typical dystrophic features with extensive endomysial fibrosis and marked atrophy of myosin heavy-chain IIa fibers. There were more PAX7-positive cells in all CPM versus other muscles (n = 5, control; n = 3, inclusion body myositis), and they were more numerous in OPMD CPM versus control normal CPM without any sign of muscle regeneration. Intranuclear inclusions were present in all OPMD muscles but unaffected OPMD patient muscles (i.e. sternocleidomastoid, quadriceps, or deltoid; n = 14) did not show evidence of fibrosis, atrophy, or increased PAX7-positive cell numbers. These results suggest that the specific involvement of CPM in OPMD might be caused by failure of the regenerative response with dysfunction of PAX7-positive cells and exacerbated fibrosis that does not correlate with the presence of PABPN1 inclusions.

Effect of Suturing the Silicone Rod to the Tarsal Plate and the Suture Material Used on Success of Frontalis Suspension Surgery

To evaluate the effect of suturing the silicone rod to the tarsal plate and the suture material used in suturing on surgical success of frontalis suspension for congenital ptosis. Eighty eyes of 56 consecutive patients who underwent frontalis suspension surgery using silicone rods for congenital ptosis between 2005 and 2011 were included in this retrospective study. The surgical results of eyes were compared, in which silicone had not been sutured to the tarsal plate (group 1), with those sutured with monofilament polypropylene suture (group 2), and those sutured with polybutylate-coated braided polyester suture (group 3). Surgical success indicated that the postoperative eyelid position was maintained within 1 mm of the normal eyelid position, that is, 1 mm below the superior limbus in bilateral cases and the same level with the other eyelid in unilateral cases, in the primary position of gaze. Postoperative eyelid level beyond these limits was defined as surgical failure. The mean follow up was 16.3 months (6-38 months) and the mean age was 5.48 years (1-24 years). Thirty were male and 26 were female patients. Surgical failure occurred in 9 of 18 (50%) cases in group 1, in 5 of 24 (20.8%) cases in group 2, and in 5 of 38 (13%) cases in group 3 during the follow-up period after adequate eyelid elevation had been achieved just after the operation. The difference between surgical success rates in group 1 and group 2 (p = 0.047) and group 1 and group 3 (p = 0.003) was statistically significant. However, the difference between group 2 and group 3 did not reach statistical significance. Suturing the silicone rod to the tarsal plate increases the surgical success rates of frontalis suspension surgery for congenital ptosis. Suturing with polybutylate-coated braided polyester, even though statistically insignificant, seems to be more effective than suturing with monofilament polypropylene.

Eyelid Surgery in Ocular Myopathies

ABSTRACTObjective: To retrospectively analyse surgical outcome and complications in patients with ocular myopathy undergoing ptosis correction and to introduce preoperative prophylactic lower lid elevation in this group.Methods: The medical records of all ocular myopathy patients who had undergone oculoplastic surgery between June 1995 and May 2006 were obtained. Patients’ demographics, surgical details and measurements, and complications were recorded.Results: 29 patients were identified; 21 with chronic progressive external ophthalmoplegia (CPEO), 7 with myotonic dystrophy (MD) and 1 with oculopharyngeal muscular dystrophy (OPMD). Then, 61 procedures to adjust eyelid height were performed, comprising levator resection, brow suspension, anterior lamellar repositioning, lower lid elevation and upper lid lowering. Palpebral aperture was significantly increased in all patient groups, by procedure and diagnosis, more significantly following brow suspension compared with levator resection. The patients’ feedback was very positive. Post-operative complications were few, included corneal exposure and ulceration, ptosis recurrence, arched brow, and sling infection, all of which were successfully treated.Conclusion: Our results demonstrate subjective and objective benefit following surgery in these patients, with a low complication rate. The use of pre-operative prophylactic lower lid elevation procedures is a promising modality.

The Modified Fasanella-Servat Procedure

To describe a modified Fasanella-Servat procedure and nomogram for the correction of minimal amounts of ptosis. Retrospective review of this modified Fasanella-Servat procedure was performed on 118 eyelids in 86 consecutive patients over 2, 4-year periods by 1 surgeon (S.C.D.). The amount of tarsectomy was based on the amount of ptosis. Mean pre- and postoperative margin-to-reflex distance 1 were +0.7 mm and +2.4mm, respectively. One hundred and twelve eyelids (95%) had satisfactory results with postoperative margin-to-reflex distance 1 ≥ 1.5 mm. Eyelid symmetry was achieved in 92% of eyelids to within 0.5 mm. There was no incidence of overcorrection, tarsal buckling, or corneal abrasion. One eyelid had a contour deficit. Tarsectomy amount ranged from 2 mm to 5 mm. Average amount of tarsectomy to eyelid elevation was 2.4:1. The modified Fasanella-Servat procedure is technically easy, time-efficient, and has a low complication rate for the treatment of minimal blepharoptosis (< 2.5 mm) with good levator function and negative phenylephrine test. In the authors' hands, the ratio of tarsectomy to eyelid elevation is approximately 2:1. In addition to other techniques such as levator advancement and Müller's muscle conjunctival resection, the modified Fasanella-Servat technique is a useful adjunct to the modern ptosis surgeon's armamentarium.

Outcomes of Mild to Moderate Upper Eyelid Ptosis Correction Using Müllerʼs Muscle–Conjunctival Resection

Müller's muscle-conjunctival resection is used to correct mild to moderate ptosis commonly encountered in the rejuvenation patient population. The authors examined its efficacy and analyzed variables that potentially affect outcomes. Patients who underwent ptosis correction using Müller's muscle-conjunctival resection with greater than 10-month follow-up were included. Amount of ptosis reduction, eyelid symmetry, effects of concomitant facial aesthetic operations, and adverse outcomes were analyzed. Patients were grouped into medium- (<24 months after surgery) and long-term follow-up (>24 months) cohorts to determine whether outcomes changed over time. Forty patients with a mean follow-up of 28 months combined for a total of 70 resection operations. Resection significantly reduced ptosis by a mean of 1.48 ± 0.88 mm (p < 0.001), corresponding to 0.19 mm of eyelid elevation for every 1.0 mm of Müller's muscle resected. The procedure successfully corrected 84 percent of eyelids to within 0.5 mm and 94 percent to within 1.0 mm of normal eyelid position. On patients with asymmetric ptosis, it significantly improved eyelid symmetry to within 1.0 mm from 85 percent of patients before surgery to 95 percent after surgery, and to within 0.5 mm from 53 percent before surgery to 75 percent of patients after surgery (p = 0.036). Furthermore, the mean correction of ptosis was not significantly different between medium- (1.58 ± 0.93 mm) and long-term (1.32 ± 0.93 mm) follow-up patients (p = 0.258). Müller's muscle-conjunctival resection is an effective long-term solution to mild to moderate eyelid ptosis and asymmetry, and can be effectively performed concomitantly with other aesthetic facial procedures. Therapeutic, IV.

Internal Cantholysis for Repair of Moderate and Large Full-Thickness Eyelid Defects

To determine the safety and efficacy of internal cantholysis for closure of larger full-thickness eyelid defects. Retrospective review of a consecutive case series. Eighteen patients (18 eyelids) underwent internal cantholysis for repair of a moderate or large full-thickness eyelid defect during the study period. Retrospective review of a consecutive case series of all patients undergoing transconjunctival lateral cantholysis for repair of moderate and large full-thickness eyelid defects between October 2008 and November 2010. Moderate was defined as ≥ 14 mm in horizontal length, and large was defined as ≥ 20 mm in horizontal length. Charts were reviewed for patient demographics; indication for surgery; defect size, type, and location; other concomitant repair; follow-up interval; and complications. Eighteen patients (18 eyelids) underwent internal cantholysis for repair of a moderate or large full-thickness eyelid defect during the study period. Average patient age was 73 years (range, 45-94 years), and there were 10 male and 8 female patients. Average defect size was 19.0 mm (range, 14-25 mm). Average follow-up interval was 4.6 months (range, 1-12 months). Complications included eyelid margin notch (3 cases), persistent canthal dystopia (3 cases), trichiasis (2 cases), pyogenic granuloma (2 cases), eyelid margin nodule (1 case), lower eyelid elevation of 1 mm (1 case), and mild resolving medial lagophthalmos (1 case). No patient requested or required further surgery on the operated eyelid for any reason during the study period. Internal cantholysis allows for closure of moderate and large full-thickness eyelid defects. Complications are acceptable in light of the morbidity of other therapeutic options, such as semicircular flap or shared eyelid flap procedures.

Correction of paralytic lagophthalmos

Bell's palsy causes lagophthalmos of the involved eyelids. Secondary to the atonicity of the eyelids, xerophthalmia, conjunctivitis and epiphora develops. There are dynamic (muscle transfers) and static (gold weights, tarsorrhaphy) approaches to alleviate these problems. The GOALS of this study are to present a technical note for a surgical method for lengthening the retracted upper eyelid with autogenous temporalis fascia and elevation of the lower eyelid with transplantation of autogenous morselized conchal cartilage graft via standard blepharoplasty incisions. The proposed technique is illustrated in details with an example of a patient with paralytic lagophtalmos. The 4 years follow up of the case operated by this technique shows a stable occlusion of the eyelids with a lowering of the upper eyelid and elevation of the lower eyelid margin. If the paralysis is complete this technique will not accomplish adequate relieve of symptoms. In this cases re-animation of the eyelids with either temporalis muscle transfers or free micro neurovascular muscle transfers are indicated.

Repeat Posterior Lamellar Grafting for Recalcitrant Lower Eyelid Retraction Is Effective

Purpose: To review one surgeon’s (J.H.O.) experience with repeat retractor release and posterior lamellar grafting in patients with residual lower eyelid retraction. To quantify the amount of eyelid elevation expected from each procedure.Method: Retrospective chart review of patients with repeat posterior lamellar grafting between 1992 and 2010. Patients were grouped into thyroid associated orbitopathy (TAO) and other causes. Hard palate mucosa or free tarsoconjunctiva grafts were used. Preoperative and postoperative inferior scleral show, lagophthalmos, superficial punctate keratopathy, and patient symptoms were recorded. Outcome measures were changes in scleral show and lagophthalmos with each procedure. Combined results were examined.Results in patients with TAO were analysed separately and compared with other etiologies.Results: In this series, a single procedure is expected to reduce scleral show by a mean of 1.63 mm (76%) and lagophthalmos by a mean of 0.48 mm (55%). A second procedure can further reduce residual scleral show by a mean of 0.71 mm (80%) and residual lagophthalmos by a mean of 0.43 mm (76%). Patients with TAO were more likely to have larger measurements of preoperative scleral show (1.40 mm versus 0.46 mm, p < 0.001). Patients with other etiologies were more likely to have larger measurements of preoperative lagophthalmos (1.25 mm versus 0.47 mm, p = 0.004).Conclusions:This is the first study to evaluate outcomes of recalcitrant lower lid retraction requiring repeat posterior lamellar grafting. Mean reductions in scleral show and lagophthalmos can be used as a guide in the preoperative evaluation and counseling of patients with lower lid retraction.

Primary bilateral silicone frontalis suspension for good levator function ptosis in oculopharyngeal muscular dystrophy

AimTo evaluate outcomes of patients with oculopharyngeal muscular dystrophy (OPMD) with levator function (LF) ≥10mm who underwent primary bilateral silicone frontalis suspension.Methods31 patients with OPMD satisfied the following inclusion criteria:...

Outcomes of Lower Eyelid Cicatricial Entropion With Grey-Line Split, Retractor Recession, Lateral-Horn Lysis, and Anterior Lamella Repositioning

To report indications and outcomes of a technique for the correction of lower eyelid cicatricial entropion using a lower eyelid gray-line split, inferior retractor recession, lateral-horn lysis, and anterior lamella repositioning. Retrospective, 5-year, single-center, consecutive case series of patients with lower eyelid cicatricial margin entropion undergoing the above procedure. Patients with significant inferior fornix contraction or symblepharon undergoing concurrent fornix reconstruction with buccal mucosal grafts at the same time as lamella repositioning were excluded. Outcomes were assessed based on the review of medical case notes and clinical photographs assessed independently. Success was defined by: 1) improvement in eyelid position and 2) improvement in lower eyelid retraction. Twenty-one eyelids of 19 patients (mean age 57.7 ± 22.6 years, range 5-95 years, 8 men and 11 women) were included. The mean follow up was 27.4 ± 16.8 (range 3.2-59.6) months. The causes of cicatricial entropion were as follows: ocular cicatricial pemphigoid (6), Stevens-Johnson syndrome (3), previous eyelid reconstruction (2), socket scarring (2), thermal burn (1), chemical burn (3), postradiotherapy (1), and meibomian gland dysfunction (1). A second procedure was carried out in 38% (8/21) of eyelids within 1 year. Within 3 years, 10% (2/21) and 5% (1/21) of eyelids required a third and fourth procedure, respectively. The most common lower eyelid revision procedures included anterior lamellar repositioning. Other procedures required included buccal mucous membrane grafts, everting sutures, and lateral tarsorrhaphy. Three patients with loss of >50% inferior fornix depth were included. Two had previously undergone mucosal grafts and 2 required subsequent mucosal grafts. Overall, 90% (19/21) of eyelids eventually achieved improvement in lower eyelid position following repeat surgery, including mucosal grafts in 3 eyelids. Mid-pupil lower eyelid elevation was 1 mm in 6 of 19 (32%) patients and lower eyelid lateral retraction significantly improved in 9 of 19 (47%) patients. Based on the principles of lamella repositioning and posterior middle lamella release with formal retractor recession through a gray-line incision, this technique is of value as a lash-preserving procedure in moderate-to-severe cicatricial lower eyelid entropion, particularly where tarsoconjuctival contraction or eyelid margin distortion exists.

Effects of varying subthalamic nucleus stimulation on apraxia of lid opening in Parkinson’s disease

Apraxia of lid opening (ALO) is a non-paralytic inability to open the eyes or sustain lid elevation at will. The exact pathophysiological mechanisms underlying the syndrome are still unknown. ALO has been reported in patients with Parkinson's disease (PD) after subthalamic nucleus (STN) deep brain stimulation (DBS), suggesting a possible involvement of the basal ganglia. We aimed to assess the effects of varying STN stimulation voltage on ALO in PD patients. Seven out of 14 PD patients with bilateral STN stimulation consecutively seen in our centre presented with ALO. We progressively increased voltage on each STN, using either 130 Hz (high-frequency stimulation, HFS) or 2 or 3 Hz (low-frequency stimulation, LFS). In five patients, HFS induced ALO time-locked to stimulation in 7 out of 10 STNs at a voltage higher than that used for chronic stimulation. LFS induced myoclonus in the pretarsal orbicularis oculi muscle (pOOm) with a rhythm synchronous to the frequency. In the other two patients with ALO already present at the time of the study, HFS improved ALO in 3 out of 4 STNs. ALO recurred within minutes of stimulation arrest. Our findings show that STN-DBS can have opposite effects on ALO. On the one hand, ALO is thought to be a corticobulbar side effect due to lateral current spreading from the STN, in which case it is necessary to use voltages below the ALO-inducing threshold. On the other hand, ALO may be considered a form of off-phase focal dystonia possibly improved by increasing the stimulation voltages.