Involutional Blepharoptosis Research Articles

Preoperative asymmetry is a risk factor for reoperation in involutional blepharoptosis

Patients with involutional blepharoptosis sometimes require reoperation because of functional or esthetic reasons after the primary operation. Few studies have analyzed the risk factors for reoperation in such cases. We retrospectively analyzed the cases of 274 patients who underwent levator aponeurosis surgery for bilateral involutional blepharoptosis. We examined the risk factors for reoperation using univariate and multivariate analyses. Reoperation was performed for 89 of the 274 patients (32.5%). There was no significant difference in the rate of reoperation among surgeons. In the univariate analysis, patients with preoperative asymmetry, defined as a difference of >1mm in the marginal reflex distance between the right and left sides, showed a significantly higher rate of reoperation (42.7%) than those without asymmetry (28.1%) (p=0.018). Age, sex, and ptosis severity did not affect the rate of reoperation. The multivariate analysis with a logistic regression showed that preoperative asymmetry was a significant risk factor for reoperation, with an odds ratio of 1.90 (p=0.019). In involutional blepharoptosis, patients with preoperative asymmetry should be informed of the higher risk of reoperation, and the balance between the right and left sides should be carefully adjusted intraoperatively.

Quantitative Comparison of the Effect of 10% Phenylephrine Instillation and Manual Elevation in Patients with Involutional Blepharoptosis

Objective: To compare the effect of 10% phenylephrine (PE) instillation and manual elevation (ME) on the upper eyelid position of the tested eye and the contralateral eye in patients with involutional blepharoptosis (IB). Methods: IB patients were submitted to two tests followed by observation of the effect on the contralateral eyelid: (1) ME of the more ptotic eyelid; and (2) instillation of two drops of 10% PE (phenylephrine test) in the more ptotic eye. The patients were filmed before and 5, 10, and 15 minutes after instillation. The upper eyelid margin reflex distance (MRD1) was measured using the software Image J, and the results were analyzed with the linear mixed-effects model. Results: The study included 70 patients aged 44–86 years, 64 of whom were female (91.43%), divided into three groups: subjects with unilateral IB, subjects with bilateral IB, and controls. The eye submitted to instillation with 10% PE displayed significant elevation during the first 10 min: from 1.33 ± 0.66 mm to 2.06 ± 0.89 mm (unilateral group), from 1.26 ± 0.63 mm to 2.29 ± 0.86 mm (bilateral group), and from 3.12 ± 0.68 mm to 4.06 ± 0.92 mm (control group). MRD1 decreased in the contralateral eye in IB patients, significantly more so after the phenylephrine test: PE vs. ME = 18.9% versus 17.2% reduction in the unilateral group, and 13.6% versus 10.7% reduction in the bilateral group. The outcome was not influenced by IB severity and the concurrence of IB and eye dominance. Conclusion: Both ME and 10% PE affected the contralateral upper eyelid, but the response was significantly better with the latter.

Distinct features in Koreans with involutional blepharoptosis.

The authors intended to present the distinct characteristics in Korean patients with involutional ptosis that deviate from typically defined features. This is a prospective observational study of 162 Korean patients with involutional ptosis. The patients underwent levator aponeurosis advancement surgery from January of 2006 to June of 2013. Patient characteristics including eyelid crease, palpebral fissure width, levator function, and the shape and condition of the levator muscle and aponeurosis were assessed. Of 279 total eyes in 162 patients, high eyelid crease and levator aponeurosis disinsertion from the tarsal plate were observed in 19.7 percent and 13 percent of the eyes, respectively. Moderate to severe fat tissue infiltration on the levator muscle was noted in 90.6 percent of the eyes. Patients were older (p = 0.002) and the eyelid drooping was more severe (p < 0.001) in cases with more fat infiltration. Levator function was inversely proportional to the degree of fat tissue infiltration (p = 0.037). Slightly decreased levator function, infrequent high eyelid crease occurrence, thick and puffy eyelids, low incidence of levator aponeurosis disinsertion from the tarsal plate, and prominent fatty infiltration on the levator muscle are distinct and unique characteristics of involutional ptosis in Korean patients.

Intraoperative Adjustment of Eyelid Level in Aponeurotic Blepharoptosis Surgery

There have been numerous reports on the use of aponeurotic surgery to correct involutional blepharoptosis. However, it is still difficult to determine optimal eyelid level during operation. Here we present our new method to adjust eyelid level intraoperatively. After the aponeurosis was temporally sutured to the tarsus, while still in the supine position, the patient was asked to look up, and the position of the eyelid margin was confirmed. The margin should be located above the pupil but within the cornea while the patient gazes up. And it is ideal if the eyelid position is located in the upper half of this range. Although 3 of 29 patients were reoperated on in the follow-up period, only 1 patient required readjustment in the perioperative period. Our method is simple, easy and reduces operative time, because it is not necessary to change patient position during the operation.

The Significance of Minimal Adjustments in the Muller’s Muscle and Conjunctiva Resection Procedure to Achieve the Phenylephrine Result

Purpose: To determine if adjusting the resection amount within a small range has a significant effect in the amount of lift achieved when performing the Muller’s muscle and conjunctiva resection procedure (MMCR).Methods: A retrospective chart review was performed analyzing 102 eyelids of 68 patients with involutional blepharoptosis that had a MMCR resection amount ranging from 8.0–9.5 mm performed by a single surgeon (P.S.)Results: The average lift for all resections was 2.30 mm. When comparing amongst all resection groups, there was no significant difference in the amount of lift obtained (p = 0.2454).Conclusion: When performing the MMCR procedure, adjusting the resection amount within a small range of 8.0–9.5 mm does not affect the amount of lift achieved.

Oxidative stress in the levator aponeurosis in Asian involutional blepharoptosis.

To analyze the histopathology and expression of 8-hydroxydeoxyguanosine (OHdG), a marker of oxidative stress, in the levator aponeurosis tissues of involutional aponeurotic and congenital blepharoptosis patients, and adult subjects with no history of blepharoptosis. Fourteen and 4 levator aponeurosis tissues obtained from Asian patients with involutional and congenital blepharoptosis and 3 normal adult tissues were examined. All tissues were fixed in 4% paraformaldehyde, embedded in paraffin, and then submitted for hematoxylin and eosin staining and immunohistochemistry with anti-8-OHdG antibody. The levator aponeurosis tissues contained spindle smooth muscle fibers and striated muscles. Nuclear immunoreactivity for 8-OHdG was noted in striated and smooth muscle cells in all the tissues. The 8-OHdG-positive rate was significantly lower in congenital blepharoptosis than involutional blepharoptosis (p < 0.05). Moreover, the number of 8-OHdG-positive striated muscle cells was significantly higher in the involutional blepharoptosis than normal tissues (p < 0.05). In contrast, there was a rare positive 8-OHdG-immunoreactivity of smooth muscle cells in the aponeurotic tissues of the involutional blepharoptosis patients. Levator aponeurosis in involutional aponeurotic blepharoptosis tissues showed oxidative stress in the muscle, indicating that oxidative stress plays a potential role in the pathologic study of the disease.

Evaluation of Polybutylate-Coated Braided Polyester (Ethibond) Sutures for Levator-Advancement Blepharoptosis Repair

Purpose. To evaluate the efficacy and safety of polybutylate-coated braided polyester (Ethibond* 5-0) suture for levator aponeurosis suturing to the anterior tarsal surface in involutional blepharoptosis repair surgery. Methods. Ten consecutive patients (16 eyes) with acquired blepharoptosis which resulted from levator aponeurosis dehiscence with good levator function had gone through surgery and were followed up for, at least, one year. Results. There was no significant change between postoperative MRD1 measurements. No serious complications, such as infection of the sutures, inflammation, granuloma formation or ptosis recurrence, were registered. Conclusion. Polybutylate-coated braided polyester (Ethibond* 5-0) suture is a safe and effective material for involutional blepharoptosis repair surgery.

Dyslipidaemia and age-related involutional blepharoptosis

The aetiology of age-related involutional blepharoptosis may be multifactorial. Dyslipidaemia may be involved in the pathogenesis of this disease, as dyslipidaemia, which is often related to ageing, is a risk factor for many disorders. The relationship between lipid profiles and age-related involutional blepharoptosis was evaluated to investigate this hypothesis. There are no known reference data in the literature examining the statistical association between dyslipidaemia and age-related involutional blepharoptosis. The study population was 251 consecutive Japanese patients aged 60 years or older who had at least one of the most common age-related changes of the eyelid and eyebrow, and who underwent surgical intervention. Blepharoptosis was defined as a marginal reflex distance of <2mm. Using strict exclusion criteria applied to all the patients regardless of eyelid position, 101 patients were finally enrolled. The selected demographic and clinical characteristics, as well as biochemical parameters including plasma lipids, were statistically compared between the patients who developed pure age-related involutional blepharoptosis and those who did not. Dyslipidaemia was observed to be associated with the presence of age-related involutional blepharoptosis (odds ratio: 4.008, 95% confidence interval: 1.586-10.131, p=0.002). Univariate analysis revealed that triglycerides and non-high-density lipoprotein cholesterol were significantly higher in patients with age-related involutional blepharoptosis compared with those without blepharoptosis. With multivariate analysis, non-high-density lipoprotein cholesterol (p=0.003) and high-density lipoprotein cholesterol (p=0.044) were both significantly and independently associated with the presence of age-related involutional blepharoptosis, but in opposite directions (positive and inverse, respectively), whereas triglycerides were no longer significant. Dyslipidaemia, specifically atherogenic dyslipidaemia, should be considered as a possible determinant of age-related involutional blepharoptosis. Further studies are required to clarify the causal relationship between dyslipidaemia and age-related involutional blepharoptosis.

Plicature interlamellaire du muscle releveur de la paupière supérieure par mini incision (technique de Frueh) dans la chirurgie du ptosis : étude rétrospective sur 119 cas

To evaluate the efficacy and efficiency of the new small anterior incision, small-incision dissection procedure (Frueh's procedure) for the correction of involutional and congenital blepharoptosis. This was a retrospective study to compare different parameters between Frueh's procedure and the traditional aponeurotic anterior approach in a group of 98 involutional blepharoptosis patients and between Frueh's procedure and Whitnall's sling in a group of 21 congenital blepharoptosis patients. The main criterion was recurrence requiring reintervention. In the adult's group, the rate of reoperation was not significantly different for the two surgical procedures (p=0.82). In the children's group, the rate of reoperation was not significantly different for the two surgical procedures (p=0.3). In adults, compared with the traditional aponeurotic approach, Frueh's procedure for blepharoptosis correction is equally efficacious in correcting eyelid height, superior in producing desirable eyelid contour, and much quicker to perform. In children, Frueh's procedure is a good technique for mild and moderate blepharoptosis with a good levator function. However, Frueh's procedure in severe blepharoptosis with low levator function seems not to be as efficient as the traditional surgical techniques. This study confirms Frueh's procedure as a reference for the treatment of adults and children with blepharoptosis.

Levator Superioris Muscle Function in Involutional Blepharoptosis

Levator Superioris Muscle Function in Involutional Blepharoptosis

Blepharoptosis and External Ophthalmoplegia Associated with Long‐Term Antiretroviral Therapy

Long-term antiretroviral therapy (ART) is associated with lipodystrophy, peripheral neuropathy, lactic acidosis, and myopathy. Blepharoptosis, without prior ART association, is usually caused by age-associated involutional ptosis, but it is also seen in mitochondrial myopathies with external ophthalmoplegia, cardiac conduction disturbances, and neurological impairments. Patients presented over a 2-year period. Four patients underwent surgical blepharoptosis repair. Five human immunodeficiency virus type 1-infected patients (median age, 50 years; range, 46-53 years) who were receiving ART presented with severe blepharoptosis; 2 of these 5 also presented with external ophthalmoplegia. Findings included decreased palpebral fissure height (median, 6.5 mm; normal height, 9 mm), mildly impaired levator function (median, 10 mm; normal, >13 mm), and markedly decreased marginal reflex distance (median, 0.5 mm; normal, 4 mm). A greater advancement of the levator aponeurosis was required during surgical repair, a finding consistent more with myogenic than with involutional blepharoptosis. All patients had severe lipodystrophy, which preceded blepharoptosis by a median interval of 4.7 years (range, 2.8-5.7 years). Four patients also presented with peripheral neuropathy and metabolic abnormalities before the onset of blepharoptosis, and 3 had cardiac conduction disturbances. Patients received ART for a median of 7.8 years (range, 4.9-11.2 years), thymidine analogue-containing ART for a median of 7.1 years (range, 1.2-7.9 years), and protease inhibitor-containing ART for a median of 7.1 years (range, 4.9-8.9 years). We report the novel findings of blepharoptosis and external ophthalmoplegia in patients who are receiving ART. Ptosis was preceded by lipodystrophy with long-term use of both thymidine-analogue- and protease inhibitor-containing ART. The findings are most consistent with myogenic ptosis in a generalized mitochondrial myopathy syndrome. Clinicians should also be watchful for other potential myopathic ptosis-associated complications, including proximal weakness, dysphagia, deafness, and cardiac conduction disturbances.

Levator Superioris Muscle Function in Involutional Blepharoptosis

To assess the role of muscular degeneration, we evaluated the correlation between ptosis severity and levator muscle function. Retrospective cohort study. The medical records of 136 patients (53 men and 83 women; mean age, 67 years) with acquired blepharoptosis were reviewed for levator function (LF), margin reflex distance (MRD), age, and gender. Multivariate linear regression was performed for statistical analysis. A significant correlation (P < .001) was seen between MRD (mean, 1.0 + 1.0 mm; range, -3.0 to 3.0 mm) and LF (mean, 15.0 + 1.0 mm; range, 11.0 to 20.0 mm). On average, a 0.5-mm reduction in LF was observed for each 1.0-mm decrease in MRD. This was independent to other variables assessed. In patients with involutional blepharoptosis, a directly proportional decrease in levator function and eyelid height was observed. This may implicate an abnormality of the levator muscle itself as a contributing factor in the development of involutional blepharoptosis.

Histopathology of Blepharoptosis Induced by Prolonged Hard Contact Lens Wear

To clarify histopathologically the structural features of blepharoptosis in prolonged hard contact lens wearers. Retrospective case-control study. Biopsy specimens from identical sites at the levator aponeurosis and Mueller muscle from 15 long-term hard contact lens wearers were examined histopathologically (group 1). They comprised two men and 13 women with bilateral blepharoptosis ranging in age from 26 to 59 years (mean +/- SD, 44.4 +/- 10.70 years). The average length of hard contact lens wear was 25.4 years (range 12 to 40 years), and the average spherical equivalent refractive error was -9.100 diopters (range -2.825 to -20.375 diopters). We also examined specimens from 15 patients with involutional blepharoptosis who underwent levator resection; they comprised three men and 12 women ranging in age from 64 to 79 years (mean +/- SD, 72.3 +/- 4.38 years). All patients in group 1 manifested fibrosis and negligible fatty degeneration in Mueller muscle. In group 2, we detected mild fibrosis in Mueller muscle and fatty degeneration of the aponeurosis and Mueller muscle. Prolonged hard contact lens wear induces fibrosis in Mueller muscle and may result in contact lens-induced blepharoptosis.

Intraoperative Quantification Using Finger Force for Involutional Blepharoptosis without Postoperative Lagophthalmos

To report intraoperative quantification using finger force for involutional blepharoptosis, which helps in the prevention of postoperative lagophthalmos. We carried out levator resection on 20 involutional blepharoptic eyelids. Fissure height was examined intraoperatively to evaluate the extent of resection. If a patient presented more than 3 mm of lagophthalmos in voluntary eyelid closure but could fully open the eye, we forcibly closed the eyelid, using a finger, after voluntary eyelid closure. If more than 3 mm of lagophthalmos was still observed after forced eyelid closure, we corrected eyelid tension until lagophthalmos became less than 2 mm. Six of the ten patients (20 eyelids) presented with full eyelid opening but more than 3 mm of lagophthalmos in voluntary eyelid closure. After the upper eyelids were forcibly lowered, all six eyelids showed less than 2 mm of lagophthalmos. There were no cases of lagophthalmos 1 month postoperatively. Additional finger force makes precise quantification of blepharoptosis surgery possible and prevents postoperative lagophthalmos.

Decreased Carotenoid Content in Preaponeurotic Orbital Fat of Patients With Involutional Ptosis

The underlying cause of involutional blepharoptosis is unknown. The carotenoid content of preaponeurotic and nasal orbital fat among patients with and without involutional ptosis was evaluated to investigate the hypothesis that development of ptosis may be related to low carotenoid content of preaponeurotic orbital fat. Through a case-control design, the carotenoid content of preaponeurotic and nasal fat of 10 patients with ptosis and 11 patients without ptosis was measured by spectrophotometry analysis. Differences in carotenoid content between patients with and without ptosis were evaluated in unadjusted analyses and in multivariate models adjusted for age, sex, race, and presence of thyroid eye disease as potential confounders. The total carotenoid content of the preaponeurotic fat of patients with ptosis was 59% lower than patients without ptosis (2.98 versus 7.26 absorbance/mg, p = 0.005). When adjustments were made for age, sex, race, and presence of thyroid eye disease, this difference was attenuated, but there was still a trend toward lower preaponeurotic fat carotenoid content among patients with ptosis (p = 0.09). The carotenoid content of the nasal fat was not significantly different among patients with and without ptosis (2.69 versus 3.40 absorbance/mg, p = 0.33). A lower ratio of preaponeurotic to nasal carotenoid content was demonstrated among patients with ptosis compared with patients without ptosis (1.4 versus 2.1; p = 0.06 unadjusted, p = 0.10 adjusted). Patients with involutional ptosis show trends toward having lower carotenoid content in preaponeurotic fat. Further investigation of the potential role of orbital fat carotenoids in the development of involutional ptosis is warranted.

Aponeurotic repair of involutional blepharoptosis.

Thirty-two patients with involutional blepharoptosis were treated by reattachment of the levator aponeurosis and followed up for a minimum of one year. The median age of the patients was 68 years and they were predominantly female and had bilateral ptosis. Seven (22%) needed revisional surgery because of undercorrection. Results were evaluated using scoring from 1-4 where 1 is normal, 2 mild ptosis, 3 moderate ptosis, and 4 severe ptosis. After one operation the degree of ptosis improved from 3.2 to 1.3. Half the patients had simultaneous procedures, usually blepharoplasty, but the mean duration of operation was still only 34 minutes (range 15-77). The recovery period was short and complication rate low.

Improvement in Subjective Visual Function and Quality of Life Outcome Measures After Blepharoptosis Surgery

To examine patients' subjective perception of visual function and health-related quality of life as affected by blepharoptosis and the change in these perceptions after blepharoptosis surgery. A 27-item questionnaire pertaining to vision-related activities and symptoms was used preoperatively to assess 50 consecutive patients (18 years old or older) with unilateral or bilateral acquired involutional blepharoptosis, and postoperatively six to eight weeks after blepharoptosis repair. Of the 24 items statistically analyzed, 16 items (67%) demonstrated significant improvement postoperatively (P < .05) among the unilateral cases and 18 items (75%) showed significant improvement postoperatively (P < .05) among the bilateral cases. The four activities that improved the most after surgery for both the unilateral and bilateral groups were the ability to perform fine manual work, hanging or reaching objects above eye level, watching television, and reading. Surgical repair of acquired involutional blepharoptosis resulted in significant improvement in several aspects of patients' subjective visual function and health-related quality of life. These issues are important in determining both the indications for and outcome of blepharoptosis surgery.

Clinical use of ultrasound biomicroscopy in involutional blepharoptosis

Involutional ptosis is an acquired disorder which is caused by a defect in the levator aponeurosis. Although the histopathologic changes of the levator aponeurosis are well defined in ptotic eyelids, the status of aponeurosis in ptotic eyelids can only be recognized at surgery.Ultrasound biomicroscopy is a high frequency ultrasonography that has the unique ability to image up to 4 mm beneath the surface. The authors applied this technology to ptotic and clinically normal eyelids in order to image the appearance of the levator aponeurosis and its relation with the tarsus. Ultrasound biomicroscopy was also performed postoperatively in order to image aponeurotic re-insertion.Ultrasound biomicroscopy proved a useful method to image the levator aponeurosis. It is helpful not only in the preoperative evaluation of blepharoptosis but also postoperative demonstration of surgical reinsertion.

Levator aponeurosis elastic fiber network.

This light and electron microscopic study demonstrates an elastic fiber network (EFN) for the levator palpebrae superioris muscle complex, which forms an intricate insertion into the upper eyelid. The EFN is examined in the monkey, in a fresh exenteration specimen, and in fresh frozen cadaver specimens from both sexes of different age groups. Multiple elastic insertions of the levator aponeurosis and Muller's muscle attachment with well-organized elastic fibers are demonstrated using special staining techniques and serial microscopic sectioning. Transmission electron microscopy (TEM) confirms the ultrastructure of "mature" elastin fibers in Muller's muscle tendon and their close relationship with the elastin-related fiber, oxytalan. Current thinking concerning the nature of elastic fibers and their possible implications in acquired involutional blepharoptosis is discussed. This microscopic study of the EFN of the upper eyelid focuses attention on the multiple elastic fiber insertions of the levator muscle complex that includes the levator aponeurosis, the conjoined fascia, the lid crease area, and Muller's muscle tendon, which have not been previously described.

Worsening of Blepharoptosis in Downgaze

We report a group of patients with involutional blepharoptosis most pronounced in downgaze. Retrospective analysis was performed on all patients who underwent involutional blepharoptosis repair in a 30-month period. Physical examination and visual field testing confirmed the increased blepharoptosis in downgaze. The average increase in visual field obstruction is 12.5 degrees and the drop in the upper eyelid relative to the visual axis is 1.9 mm. We conclude that the increased visual field obstruction in downgaze in this subset of patients is significant and deserves clinical evaluation.