Levator Aponeurosis Advancement Research Articles

Immediate Postoperative Difference of Eyelid Height Based on Intraoperative Measurement of Levator Aponeurosis Advancement in Patients with Unilateral Ptosis

ABSTRACT Purpose To determine the relationship between marginal reflex distance (MRD-1) outcomes and the distance of levator aponeurosis advancement Methods This retrospective observational study included patients with acquired unilateral aponeurotic ptosis, who underwent small-incision anterior levator advancement. The distance of levator advancement, and intra-operative MRD-1 in the sitting position, were analyzed to determine a correlation between the two. Results Forty-eight patients were included. Results exhibited no direct relationship between advancement distance and MRD-1 measurements. Median and range of MRD-1 outcomes did not present a linear progression as the distance increased or decreased. A majority of advancement distances exhibited a median MRD-1 outcome of 4.00 mm (n = 3). Success criteria was met in 85.4% of surgeries performed. Conclusion Due to varying postoperative MRD-1 outcomes, surgical results cannot be accurately predicted using predetermined advancement distances. Confirming the final MRD-1 in the sitting position with subsequent adjustment is still recommended.

Changes in Eyelid Height Based on Intra-Operative Quantification of Levator Aponeurosis Advancement in Patients with Unilateral Ptosis

ABSTRACT Objective To present marginal reflex distance (MRD-1) outcomes based on intra-operative quantification of levator aponeurosis advancement. Methods Forty-eight patients with unilateral aponeurotic ptosis underwent anterior levator aponeurosis advancement. Distance of advancement intra-operatively was compared with MRD-1 outcomes at the immediate postoperative sitting, approximately 1 week, and 1 month period. Surgical success was defined as a symmetric MRD-1 or an MRD-1 within 1 millimeter of the contralateral eyelid. Results Most MRD-1 exhibited the following trends: 1) initial decrease at about 1 week and increase at 1 month (n = 11), 2) initial increase at about 1 week with levelling at 1 month (n = 8), and 3) increasing through time (n = 7). Success rate significantly decreased through time (p = .0464). The change in proportion of successful and failed surgeries was insignificant. Surgical revision rate was 10.4%. Conclusion Levator aponeurosis advancement distances do not correlate with MRD-1 outcomes linearly. MRD-1 exhibited stability over time with a satisfactory success rate at 1 month.

The Effect of Ptosis Surgery on Meibomian Glands and Dry Eye Syndrome.

To investigate the effect of ptosis surgery on dry eye disease as measured by dry eye parameters and meibomian gland function. This prospective, case series study included patients with involutional ptosis with no prior history of dry eye disease who were scheduled for a levator aponeurosis advancement procedure. Dry eye evaluation included the ocular surface disease index (OSDI) questionnaire as well as objective measurements, which included meibomian gland loss measured by meibography, meibomian gland disease grading, tear breakup time (TBUT), corneal and conjunctival fluorescein staining, tear meniscus height, and Schirmer testing. All dry eye measurements were recorded preoperatively and repeated 21-28 days postoperatively. A total of 30 eyes were included with a mean age of 65.6 ± 11.9 years. There was a significant improvement in margin reflex distance1 (MRD1) postoperatively ( p < 0.001) and a significant decrease in upper lid margin thickening ( p = 0.022). There were no significant differences between the pre- and postoperative measurements in meibomian gland loss, TBUT, corneal and conjunctival fluorescein staining, tear meniscus height, and the Schirmer test. OSDI was increased nonsignificantly postoperatively (16.094 vs. 24.296, respectively, p = 0.107). The levator aponeurosis advancement procedure does not affect the eyelid meibomian glands, nor does it cause an increase in dry eye signs and symptoms, according to the measured parameters.

Tarsal Buckling and Entropion after Levator Aponeurosis Advancement in Patients with Floppy Eyelid Syndrome.

Two patients with floppy eyelid syndrome presented with severe eye pain and foreign body sensation after recent levator aponeurosis advancement. The examination in both patients was notable for entropion of the upper eyelid, and upper lid eversion revealed deformity of the tarsus in both patients. Surgical revision with full-thickness horizontal tarsotomy and limited excision of the abnormal tarsus corrected the deformity. The authors propose a mechanism for this phenomenon and a modification of surgical technique that may prevent this complication.

The Feasibility of Surface Electromyography in Monitoring Orbicularis Oculi Recovery after Anterior Approach Levator Aponeurosis Advancement.

Introduction: In this article, we propose a new application for eyelid surface electromyography (sEMG). By placing the electrode in the mid-pretarsal area of the upper eyelid, one can easily perform a fast examination and achieve repeatable results. We believe that this technique may increase the feasibility of eyelid sEMG in clinical practice. Methods: 126 sEMG examinations of the upper eyelid were performed by using the above-described method. Thirty-nine controls and 29 ptotic patients were enrolled. The controls underwent one measurement while the ptotic patients were employed for four sessions: Before anterior approach levator aponeurosis advancement (LAA), 2 weeks, 3 months, and more than 6 months after surgery. The relaxation and maximal contraction of the orbicularis oculi muscle (OOM) using root mean square (RMS) values were measured. Results: The results showed a statistically significant decrease in RMS values of the maximal contraction of the OOM 2 weeks after surgery (p < 0.05) and 3 months after surgery (p = 0.03). Six months postoperatively, there were no statistically significant differences in OOM activity compared to preoperative values (p = 0.2). Conclusions: Eyelid sEMG may be a useful diagnostic tool in post-operative OOM recovery monitoring. sEMG parameters of the maximal contraction of the OOM normalize within 6 months after anterior approach LAA. Electrode placement in the mid-pretarsal area of the upper eyelid offers several advantages and therefore may enhance the feasibility of sEMG in clinical practice.

Comparison of postoperative recurrence rates between levator aponeurosis advancement and external Müller's muscle tucking for acquired blepharoptosis

Treatment options for acquired blepharoptosis include levator resection, levator aponeurosis advancement (LAA), Müller's muscle-conjunctival resection (MMCR), and frontalis suspension. Previously, we reported a technique called external Müller's muscle tucking (EMMT) using the Müller's muscle as a power source. In this study, we compare LAA with EMMT and evaluate the recurrence and reoperation rates. LAA was performed on 96 eyelids in 51 patients. The average follow-up period was 12.2 months, recurrence occurred in four eyelids (4.2%) of three patients, and reoperation was required in one eyelid of one patient (2.0%). EMMT was performed on 94 eyelids in 51 patients, the mean follow-up period was 10.5 months, recurrence occurred in 14 eyelids (15%) of 10 patients, and reoperation was required in three eyelids of two patients (3.9%). A comparison of LAA and EMMT recurrence showed that EMMT was associated with a significantly higher recurrence rate (P = 0.0021). The causes of EMMT recurrence included thinning and fatty degeneration of Müller's muscles, necrosis of ligated Müller's muscles, and less postoperative scar formation. There was no correlation between EMMT recurrence and the severity of the blepharoptosis.

Utility and safety of low-concentration nitrous oxide anesthesia in ptosis surgery.

To evaluate the utility of low-concentration nitrous oxide (N2O) anesthesia in ptosis surgeryThis study was a retrospective consecutive case series that included 54 successive patients with blepharoptosis who underwent bilateral levator aponeurosis advancement and on whom skin resection performed by the same surgeon between August 2016 and July 2017. Among these patients, 27 were operated with a local anesthesia injection (air group) and 27 with a local anesthesia injection and low-concentration N2O anesthesia (N2O group). All N2O cases used a total of 6 L of gas comprising 70% oxygen and 30% N2O. Preoperative and postoperative blood pressure (BP) and heart rate (HR) and intraoperative pain, anxiety, nausea, and memory were measured immediately after surgery using visual analog scale score (VASS). Additionally, perioperative side effects were examined.There was no significant difference in age, sex, and preoperative and postoperative margin reflex distance (MRD) between the 2 groups (all P > .05). The intraoperative mean peripheral oxygen saturation was significantly higher (97.5% ± 1.6% vs 99.5% ± .6%, P < .001), intraoperative HR was significantly lower (78.2 ± 12.8 vs 70.7 ± 11.6 bpm, P = .02), and operation time was significantly shorter (33.1 ± 8.1 vs 29.4 ± 10.3 minutes, P = .03) in the N2O group than in the air group.Difference between intraoperative and preoperative systolic BP (BPs) (+15.8 ± 18.0 vs + 3.1 ± 21.7 mm Hg, P = .02), diastolic BP (BPd) (+7.0 ± 17.4 vs −2.3 ± 13.6 mm Hg, P = .04), and HR (3.2 ± 8.5 vs −3.9 ± 9.4 bpm, P = .01) was significantly lower in the N2O group than in the air group.VASS of intraoperative pain was significantly lower in the N2O group than in the air group (49.5 ± 24.7 vs 22.6 ± 14.9, P < .001), whereas intraoperative anxiety and memory did not present significant differences between the groups (P = .09 and P = .45, respectively). Intraoperative nausea score was 0 for all cases in both groups. There was no other side effect.Ptosis surgery with anesthesia using 30% N2O may effectively suppress intraoperative BP and HR along with pain and shorten the operation time without side effects such as nausea.

Digital Image Analyses of Preoperative Simulation and Postoperative Outcome following Blepharoptosis Surgery.

Background:Before blepharoptosis surgery, simulation of eyelid features, including lid height and crease position, is often performed. However, discrepancies of the simulation and outcome can occur. The purpose of this study was to analyze the pre- and postoperative images and to evaluate factors contributing to the discrepancies.Methods:Forty-one involutional blepharoptosis patients (68.2 ± 7.1 years) underwent levator aponeurosis advancement. A semicircular bent wire was used to push the preoperative ptotic eyelid up to simulate the postoperative appearance of the eyelid. Digital images of the simulation were compared with the appearance at 3 months after the surgery. The ImageJ software was used to analyze the pre- and postoperative margin reflex distance-1 (MRD-1), pretarsal show (PTS), fissure height (FH), and ocular surface area (OSA). Factors with a potential of affecting the predictability of simulation were determined.Results:During simulation, the MRD-1 was 3.6 ± 0.4 mm, the PTS was 3.48 ± 1.2 mm, the FH was 8.5 ± 0.9 mm, and the OSA was 120.7 ± 22.3 mm2. After the surgery, the corresponding values were 3.3 ± 1.2 mm, 3.3 ± 1.5 mm, 8.6 ± 1.4 mm, and 119.1 ± 25.1 mm2, respectively. The postoperative MRD-1 was significantly smaller than that of the simulation (P = 0.005, paired t test). The MRD-1 simulation error was positively correlated with the length and width of the skin resection (all P < 0.05), and the PTS error was positively correlated with the length of the skin resection (r = 0.332, P = 0.031) and negatively correlated with the preoperative OSA (r = −0.588, P = 0.007).Conclusions:The postoperative appearance of the eyelid can be simulated fairly accurately by pushing up the upper eyelid with a curved wire. However, the MRD-1 tended to be overestimated, especially for cases requiring a large skin resection.

Pathological features of levator aponeurosis in patients with involutional blepharoptosis

Objective: To observe pathological features of levator aponeurosis in patients with involutional ptosis. Methods: A prospective study. Twenty-nine consecutive patients with involutional blepharoptosis who underwent levator aponeurosis advancement surgery for blepharoptosis correction were enrolled at Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University from 2007 to 2013. Twenty-nine specimens of the levator aponeurosis were obtained during surgery. Hematoxylin-eosin staining, Van Gieson staining, Masson staining, immunohistochemistry and transmission electron microscope observations were performed to observe the features of levator aponeurosis. Twelve normal specimens of fresh levator aponeurosis were obtained from Beijign Tongren Eyebank as control group. Mann-Whitney's U-test and multiple linear regression were used for statistical analysis. Results: Among the enrolled cases, there were 19 males and 10 females;14 cases were diagnosed with moderate ptosis and 15 cases with severe ptosis;9 cases involved with both eyes, 9 cases with right eyes, and 11 cases with left eyes. The mean age was 59 years. Among the 12 normal cases, there were 5 males and 7 females. The mean age was 56 years. Histopathological observation showed fascicle disruption(+++, ++, + 24, 2, 3 vs. 0, Z=-5.666, P<0.001), scarcity of cross-striations(+++, ++, + 23, 2, 4 vs. 0, Z=-5.582,P<0.001), collagen fibers hyperplasia(+++, ++, + 15, 10, 4 vs. 0, Z=-5.223,P<0.001), fatty infiltration(+++, ++, + 24, 5, 0 vs. 0, Z=-5.671,P<0.001), and a decrease of myoglobin expression(+++,++,+,- 9, 1, 1, 15 vs. 8, 1, 0, 0, Z=-3.004, P=0.005) in levator aponeurosis. Transmission electron microscope recorded presence of collagen fiber hyperplasia and cellular degeneration including mitochondria swelling and hyperplasia, vacuoles, lipid droplets, nucleus pycnosis, chromosome condensation, disintegrated organelles, myeloid body and autophagy. Multivariate linear regression showed a correlation between fat infiltration and age(β=0.425, P=0.043) while suspicious related clinical features as independent variables and observed histopathological features as dependent variables. Conclusion: The levator aponeurosis appears to be involved with muscle fiber degeneration, collagen fiber hyperplasia and cellular degeneration in patients with involutional blepharoptosis. (Chin J Ophthalmol, 2018, 54: 671-677).

Eyelid Contour Analysis Following Müller's Muscle-conjunctival Resection and Levator Aponeurosis Advancement in Mild to Moderate Belpharoptosis

Eyelid Contour Analysis Following Müller's Muscle-conjunctival Resection and Levator Aponeurosis Advancement in Mild to Moderate Belpharoptosis

Digital Analysis of Eyelid Features and Eyebrow Position Following CO2 Laser-assisted Blepharoptosis Surgery.

Background:To compare the margin reflex distance of the upper (MRD-1) and lower (MRD-2) eyelids and the eyebrow height (EBH) in patients with involutional and hard contact lens wear--induced blepharoptosis before and after ptosis surgery.Methods:Sixty patients with acquired blepharoptosis were studied. Group 1 consisted of 30 patients with involutional ptosis (age, 75.8 ± 6.4 years), and group 2 consisted of 30 patients with hard contact lens wear–induced ptosis (age, 50.2 ± 7.1 years). All patients underwent bilateral, CO2 laser–assisted levator aponeurosis advancement surgery. A digital image was taken in the primary position before and 2 months after the surgery. The image was analyzed by the ImageJ (NIH, Bethesda, Md.) software. Parameters included MRD-1, MRD-2, EBH, and ocular surface area (OSA).Results:After surgery, all patients had a significant increase in the MRD-1 and OSA and a decrease in the EBH (all P < 0.001). The increase in MRD-1 was significantly larger in group 1 than in group 2 (P = 0.028). The decrease of EBH was significantly greater in group 1 than in group 2 (P = 0.007). Group 1 had a slight decrease in the MRD-2, but group 2 had a significant increase after surgery (P = 0.026). The change in the OSA was not significantly different between the 2 groups.Conclusions:Digital image analyses can be used for precise measurements of the eyelid features. The disparity in the changes of eyelid and eyebrow features between the 2 groups may suggest different responses of the external eyelid muscles to surgery between cases of different etiology.

CO2 Laser Blepharoplasty for Vulnerable Elderly Patients with Severe Ptosis

OBJECTIVE: To report the success of CO2 Laser Blepharoplasty (CLB) for severe ptosis (SP) in vulnerable elder patients (VEP).MATERIALS AND METHODS: A retrospective review of 32 consecutive cases of SP was carried out between 2013-2014 at Bangkok Hospital, Ramkamhaeng Hospital, Patana Medical Center Clinic in Bangkok. All SP case (margin refl ex distance (MRD1) 0-1 mm) were aged 60 years or above, ranging between 60-84 years of age, old aged patients were 80 years or above (5 patients (15.62%)). The average age was 68.5 years, 20 of the patients were women (72.5%), and 12 were men (37.5%). Each patient had at least one or more underlying diseases: diabetes mellitus (DM) in 12 cases (37.5%), hypertension (HT) in 10 (31.25%), heart diseases (HD) (i.e. post balloon cath, cardiac intervention, coronary bypass) in 8 (25%), bleeding diathesis (i.e. ITP, cannot stop anticoagulation or antiplatelet) in 4 (12.5%), and Parkinson’s disease in 2 cases (6.25%). The levator aponeurosis advancement (LA) was performed with a CO2 laser device in Ultrapulse mode, (power 5-7 W) under local anesthesia. Light intravenous sedation for the 5 very old aged patients was added to calm and comfort them during the operation. The LA adjustment for eyelid height and contour in an upright position was selected to obtain the most consistently favorable postoperative results. MRD1 (pre-and post-op) Intra-op bleeding, post-op bleeding, pain and patient satisfaction were assessed.RESULTS: Margin refl ex distance (MRD1) pre-op = 0-1 mm, post-op average = 2.8 mm (p &lt; 0.01), low bleeding or nearly bloodless during intra-op &amp; post-op. The advantage of CO2 laser over conventional surgery is easy dissection of skin and fat tissue and especially being able to clearly identify the LA with ease. Twenty eight cases (87.5%) had mild pain or less, 4 cases (12.5%) had moderate pain, no severe pain observed. There was no serious complication or any harmful effect to the patients or their underlying diseases. All patients reported a high degree of satisfaction after the operation and were happy with their better vision and facial presentation.CONCLUSION: CLB can be a good choice for diffi cult cases, especially SP and complicated VEP.

Ptosis: An Underestimated Complication after Autologous Fat Injection into the Upper Eyelid.

Autologous fat injection into the upper eyelid is a commonly used technique in plastic surgery for volume restoration. However, ptosis, as one of the potential complications of the procedure, has been less well-discussed than other complications. To present five cases of ptosis after autologous fat injection for the correction of sunken eyelid deformity and explore its causes. In this retrospective, non-comparative, and interventional case series, we identified five patients with ptosis. All patients had a history of previous autologous fat injection into the upper eyelid, performed by different plastic surgeons. Preoperative, intraoperative, and postoperative photographs were taken to analyze the causes of ptosis. Five patients developed ptosis after autologous fat injection for upper eyelid augmentation and were referred to our group for treatment. Three of the patients had received two injections of autologous fat each. Grafted fat removal with or without levator aponeurosis advancement was required in all five cases. Ptosis can develop following autologous fat injection into the upper eyelid. Surgeons should be aware of this complication, which rarely manifests during the procedure itself. Techniques for performing autologous fat injection and knowledge of upper eyelid anatomy should be refined to avoid postprocedural ptosis. 5 Risk.

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.

The Effect of Hering's Law on Different Ptosis Repair Methods.

The Hering's law effect has significant importance in surgical planning and outcomes of eyelid surgery. The current study examined the preoperative and intraoperative effect of Hering's law in Mullerectomy and levator aponeurosis advancement. A retrospective analysis was conducted of 52 patients with unilateral ptosis who underwent surgical repair from January 2011 through June 2013. Patients underwent levator aponeurosis advancement or Mullerectomy with or without tarsectomy. Preoperative and postoperative clinical documentation and photographs were evaluated. Preoperative Hering's dependency and postoperative changes in positioning of the non-operated eyelid were measured. The decision to operate on the ptotic eye alone or on both eyelids was based on preoperative Hering's dependence and intraoperative changes in the contralateral eyelid. Fifty-two patients with unilateral ptosis were included. Average age was 63.3 ± 20.1 years (range, 22-88 years; median, 61 years); 34 (65.4%) were female. The 14 cases that were not aponeurotic (either congenital, secondary to trauma, or due to postoperative ptosis) did not need contralateral repair (p = .000). In 4 (19%) cases of Mullerectomy and in 9 (52.9%) cases of levator advancement, both eyelids required surgery (p = .029). Hering's law effect was significantly more apparent in the levator advancement approach than in Mullerectomy. Levator surgery resulted in a higher incidence of combined intraoperative and postoperative Hering's law effect than did Mullerectomy. Cases with poor levator function or congenital ptosis can be repaired unilaterally with no need for contralateral surgery. The fibrotic levator palpebrae muscle and its special innervations probably explain this phenomenon. This should be considered in surgical planning.

Posterior approach levator aponeurosis advancement in aponeurotic ptosis repair

Purpose The aim of the study was to investigate the efficiency, advantages, and disadvantages of posterior approach advancement of the levator aponeurosis in the repair of aponeurotic ptosis. Patients and methods This is a prospective interventional study, which included 27 eyelids of 20 patients with aponeurotic ptosis. The study included only cases with good levator function of 11 mm or more. Patients with significant dermatochalasis were excluded from the study. All patients were treated by posterior approach levator aponeurosis advancement under local anesthesia. Patients were evaluated 1 week, 1 month, 3 months, and 6 months postoperatively for margin reflex distance 1 (MRD1), eyelid symmetry, and eyelid crease and contour. Results The study included 27 eyelids of 20 patients with aponeurotic ptosis. The patients' mean age was 44.36 ± 14.47 years. The mean preoperative MRD1 was 1.6 ± 0.5 mm, whereas the mean levator function was 12.6 ± 1.1 mm. The mean operative time was 32.6 ± 5.4 min. The postoperative MRD1 showed significant improvement to 3.7 ± 0.6 mm (P Conclusion Posterior approach aponeurotic advancement is an effective procedure for correction of aponeurotic ptosis. It has the advantages of high success rate, good natural-looking eyelid contour, and short operative time, and the results are independent of the response to phenylephrine.

Current Ptosis Management: A National Survey of ASOPRS Members

To assess current practice patterns for management of ptosis by current ASOPRS members. An invitation to participate in a web-based, anonymous survey was sent to current members of the American Society of Ophthalmic Plastic and Reconstructive Surgeons (ASOPRS) via e-mail. The survey consisted of 4 sections: preoperative testing of ptosis patients, surgical preferences, dry eye evaluation in ptosis patients, and length of postfellowship practice. Responses were analyzed using standard statistical methods. Fifty percent of ASOPRS members performed more than 100 ptosis procedures in the past year. Most ASOPRS members performed preoperative photography, automated perimetry testing, and phenylephrine testing in evaluation of ptosis patients. A slight majority of ASOPRS members did not use preoperative Schirmer testing as the primary screening tool for dry eye disease. Most ASOPRS members performed internal levator aponeurosis advancement surgery, although most surgeons performing concurrent ptosis repair and blepharoplasty preferred an external approach. Frontalis sling surgery was performed using a wide variety of materials for suspension. Current trends in the management and preoperative evaluation of blepharoptosis by ASOPRS members revealed a number of interesting common practices that are of value to current practitioners.

Transcutaneous Blepharoptosis Surgery - Advancement of Levator Aponeurosis

Ptosis surgery has seen many advances in the last few decades, the most important of which have emerged as a result of better understanding of the anatomy and physiology of the eyelid and orbit. Anterior approaches such as a levator aponeurosis advancement, tarsoaponeurectomy and posterior repair involving resection of Muller’s muscle have proven to be effective in most cases. The focus of this article is a discussion of the indications, operative techniques, success rates and complications of transcutaneous levator advancement in detail.

Transconjunctival Levator Aponeurosis Advancement without Resection of Müller’s Muscle in Aponeurotic Ptosis Repair

The transconjunctival levator aponeurosis advancement without resection of Müller’s muscle enables repair of aponeurotic ptosis without the need for surgical exposure through a skin incision. This technique may be preferred by many patients who are reluctant to undergo ptosis surgery because of the possible skin scar and who do not present with excessive upper eyelid laxity. A successful outcome requires careful patients' selection, familiarity with the surgical anatomy of the everted eyelid, as well as with the possible complications. Special consideration should be given to factors such as determining the degree of aponeurosis advancement to accord with the height of the eyelid during surgery and to creating the desired shape and size of the “double eyelid” in Asians. From our experience, this surgical technique is effective in correcting levator aponeurotic ptosis and contributes to a quick recovery of the normal anatomy and function of the eyelid. This method should therefore be added to the arsenal of techniques for blepharoptosis repair.

Amyloidosis-Associated Neurotrophic Keratopathy Precipitated by Overcorrected Blepharoptosis

To describe amyloidosis-associated neurotrophic keratopathy. In this interventional case report, we describe the clinical findings of a patient with amyloidosis-associated neurotrophic keratopathy, precipitated by exposure from overcorrected blepharoptosis. A 70-year-old woman with a history of amyloidosis was referred with bilateral eyelid retraction 1 month after levator aponeurosis advancement surgery. Examination demonstrated visual acuities of count-fingers OD and 20/400 OS and severe corneal epithelial irregularity with diffuse fluorescein staining. She had marked eyelid retraction with 5-mm right and 3-mm left superior scleral show and incomplete closure. Corneas were anesthetic, and neurologic examination was notable for peripheral sensory loss. Despite eyelid position normalization, the corneal abnormalities progressed to large epithelial defects refractory to aggressive lubrication, punctal occlusion, bandage contact lenses, extended patching, and ultimately tarsorrhaphy consistent with neurotrophic keratopathy. One year postoperatively, the epithelial disease persists. Neurotrophic keratopathy can occur in association with amyloidosis and may be precipitated by exposure related to blepharoptosis repair.