Levator Palpebrae Research Articles

Eye and Eyelid Abnormalities Are Common in Patients with Hashimoto's Thyroiditis

Overt ophthalmopathy is presumed to be uncommon in patients with Hashimoto's thyroiditis compared to Graves' disease, where significant eye changes are found in approximately 40% of patients. On the other hand, when observing, more subtle eye changes, particularly upper eyelid retraction (UER) and mild inflammatory signs, may be common in patients with Hashimoto's thyroiditis. We have determined the prevalence and characteristics of eye signs in recently diagnosed patients with Hashimoto's thyroiditis studied prospectively since 2004 till date in Sydney (Australia). We measured serum orbital antibodies in 20 of the patients in enzyme-linked immunosorbent assay. The overall prevalence of eye signs in patients with Hashimoto's thyroiditis was 34%, of whom about a quarter had chronic UER, determined as a margin-reflex distance of >5 mm, as the main sign. There was no correlation between eye signs and cigarette smoking. Overall, there was only a modest correlation between eye signs and positive antibody tests, and 40% of patients with no eye signs at the time of study were antibody positive. Eye changes, in particular UER, are common in patients with Hashimoto's thyroiditis. Since thyroid stimulating hormone-receptor antibodies are not usually associated with Hashimoto's thyroiditis, autoimmune mediated damage of the levator palpebrae superioris (eyelid) muscle cannot be due to these antibodies. Although eyelid abnormalities may be a minor problem for most patients, for some there are major cosmetic implications requiring surgical management.

Rhabdomyosarcome palpébral chez un enfant âgé de deux ans

Rhabdomyosarcoma is an extremely virulent rare tumor whose early diagnosis considerably improves survival and visual prognosis. We report the case of a 2-year-old child with levator palpebrae superioris muscle rhabdomyosarcoma revealed by a sudden and isolated blepharoptosis. Initially, clinical and imaging investigations did not show any abnormality but a painful tumor with some hematoma quickly developed, so the investigations were repeated. The CT-scan showed an extra-conal tumor that had developed at the superior part of the orbit. Histology confirmed the diagnosis of embryonic rhabdomyosarcoma. Because of its results, treatment consisting of chemotherapy associating ifosfamide, vincristine, actinomycin and orbital radiotherapy of 40 Gy with a local addition of 10 Gy were administrated with successful results after a 3-year-follow-up.

The Supraorbital Approach to a Large Retrobulbar Cavernous Hemangioma of the Orbit-One Case Report

Purpose: To report a complete excision of a large superior orbital retrobulbar cavernous hemangioma using supraorbital craniotomy through the suprabrow approach combined with superior orbital wall removal. Case summary: A 31-year-old woman presented to our clinic with left exophthalmos beginning one month earlier. Visual acuities and intraocular pressures of both eyes were normal and there was no diplopia and no limitation in ocular movement. On exophthalmometry, the right eye was 15 mm and the left eye was 18 mm. CT and MRI demonstrated a superior orbital retrobulbar mass of 2.02.62.0 cm in size, and the mass displaced the superior rectus and levator palpebrae muscles. After six months, a neurosurgeon attempted a classic supraorbital craniotomy but failed. Fourteen months later, the authors completely excised the tumor through superior orbital wall removal. The tumor was confirmed as a cavernous hemangioma after histopathologic study. Conclusions: The authors succeeded in complete excision of a superior orbital retrobulbar cavernous hemangioma using supraorbital craniotomy through a suprabrow approach combined with superior orbital wall removal.

New Technique Combined with Suture and Incision Method for Creating a More Physiologically Natural Double-Eyelid

A combination of incision and nonincision surgical approaches is necessary to create a more physiologically natural double-eyelid. The location of the partial incision and the burying location are determined. Through a partial incision, the levator aponeurosis is isolated and fixed to the tarsal plate. A single-knot continuous suture is performed. The location of the continuous suture passing through the tarsal plate is at a level that is slightly lower than that at which the levator aponeurosis is fixed to the tarsal plate. A total of 562 patients were operated on from November of 2006 through October of 2008. The double-eyelid operation was performed on 386 patients, the upper blepharoplasty with skin excision was performed in 91 patients, and a secondary operation was performed in 85 patients. Combined mild to moderate blepharoptosis was corrected simultaneously in all cases. The follow-up period ranged from 6 months to 2 years. Individual patient recovery time varied from 2 weeks to 2 months. The advantages of the authors' technique are as follows: (1) the process of forming a double-eyelid is natural; (2) the power of the levator palpebrae muscle regarding the eye-opening process is transmitted to pull up the entire lid margin, allowing the eyes to be easily opened with minimal effort; and (3) there is minimal surgical scarring when the eyes are closed.

Transfrontoethmoidal approach to medial intraconal lesions

Object The standard superior craniotomy approach through the orbital roof is obstructed by numerous muscles, nerves, and vessels. Accessing the medial intraconal space also involves considerable brain retraction. The authors present a modified approach through the frontal sinus that overcomes these limitations. Methods Seven fixed silicone-injected cadaveric specimens were dissected bilaterally. In addition to the superior orbital wall, the ethmoidal sinuses and medial orbital wall were removed. The anatomical relationships between the major neurovascular complexes in the medial intraconal space and the optic nerve were observed. Results Intraconally, working space was created both in a "superior window" between the superior oblique and levator palpebrae muscle and in a "medial window" between the superior oblique and medial rectus muscle. The superior window mainly created an ipsilateral trajectory to the deep target. The medial window, which created a contralateral trajectory, provided a more inferior view of the medial intraconal space. Removal of the medial orbital wall further widened the exposure obtained from the superior window. The combination of these working windows makes the medial surface of the optic nerve available for exploration from multiple angles. Most of the major neurovascular complexes of the posterior orbit can be retracted safely without impinging on the optic nerve. Conclusions This novel extradural transfrontoethmoidal approach affords a direct view to the medial posterior orbit without major conflicts with intraconal neurovascular structures and requires minimal brain manipulation. The approach appears to offer advantages for medially located intraconal lesions.

61st Annual Meeting of the American Academy of Neurology Seattle, Washington April 25-May 2, 2009

61st Annual Meeting of the American Academy of Neurology Seattle, Washington April 25-May 2, 2009

Magnetic resonance imaging features in two Chinese family with congenital fibrosis of extraocular muscles

The aim of this article was to investigate the structural basis of ocular motility and visual abnormalities in humans with congenital fibrosis of the extraocular muscles (CFEOM). 17 volunteers from 2 CFEOM pedigrees Clinical ophthalmic and motility examed and 18 normal control subjects were correlated with thin-sectioned magnetic resonance imaging (MRI) across the orbit and the brain-stem level. Subjects with CFEOM had severe bilateral blepharoptosis, limited supraduction, and variable ophthalmoplegia. In affected subjects, MRI demonstrated atrophy of the levator palpebrae superioris, all EOMs, and the optic nerves, and small or absent orbital motor nerves. The oculomotor nerve was most severely hypoplastic, but the abducens was also affected. Subjects with CFEOM exhibited subclinical but highly significant reduction from normal in mean optic nerve size (P < 0.05). There are also some difference between the two CFEOM pedigrees. These findings suggest that neuronal disease is primary in CFEOM, with myopathy arising secondary to abnormal innervation and the oculomotor nucleus and trochlear nucleus of the abnormalities defects.

Upper Eyelid Anatomy

Eyelid surgery necessitates a thorough knowledge of eyelid anatomy. Recent contributions to the literature have significantly advanced our understanding of eyelid anatomy. In this review, we present an update of the anatomy and the implications for upper eyelid surgery. Aspects to be covered include the levator aponeurosis, Müller's muscle, lamina propria mucosae of conjunctiva, orbital septum, myoneural junction of the levator palpebrae superioris muscle, adipose tissue, and the ligament system.

Orexin-A inputs onto visuomotor cell groups in the monkey brainstem

Orexin-A, synthesized by neurons of the lateral hypothalamus helps to maintain wakefulness through excitatory projections to nuclei involved in arousal. Obvious changes in eye movements, eyelid position and pupil reactions seen in the transition to sleep led to the investigation of orexin-A projections to visuomotor cell groups to determine whether direct pathways exist that may modify visuomotor behaviors during the sleep-wake cycle. Histological markers were used to define these specific visuomotor cell groups in monkey brainstem sections and combined with orexin-A immunostaining. The dense supply by orexin-A boutons around adjacent neurons in the dorsal raphe nucleus served as a control standard for a strong orexin-A input. The quantitative analysis assessing various functional cell groups of the oculomotor system revealed that almost no input from orexin-A terminals reached motoneurons supplying the singly-innervated muscle fibers of the extraocular muscles in the oculomotor nucleus, the omnipause neurons in the nucleus raphe interpositus and the premotor neurons in the rostral interstitial nucleus of the medial longitudinal fasciculus. In contrast, the motoneurons supplying the multiply-innervated muscle fibers of the extraocular muscles, the motoneurons of the levator palpebrae muscle in the central caudal nucleus, and especially the preganglionic neurons supplying the ciliary ganglion received a strong orexin input. We interpret these results as evidence that orexin-A does modulate pupil size, lid position, and possibly convergence and eye alignment via the motoneurons of multiply-innervated muscle fibres. However orexin-A does not directly modulate premotor pathways for saccades or the singly-innervated muscle fibre motoneurons.

Observation on different surgical methods for children congenital blepharoptosis.

Objective To explore the clinical effect of the 3 kinds of surgery on children congenital blepharoptosis. Methods A total of 56 patients （100 eyes） with congenital blepharoptosis underwent single skin incision, divided into three groups ：the first group underwent frontalis muscle suspensions surgery for children aging from 3 month to 1.5 years . The second group underwent le- vator palpebrae shortening surgery for the children whose muscle force from 4 mm to 8 mm. The third group underwent frontale mem- brane suspensions surgery for the children whose muscle force from 0 mm to 6 mm. Results Follow up 6 month to 2 years. Frontails muscle suspensions surgery group satisfied with the results of all ca- ses. 12 years of levator palpebrae superioris shortening surgery group was under-correction. 4 eyes with double eyelid of frontale membrane suspensions surgery group was disappeared. Conclusion Frontails muscle suspensions surgery is the first choice for treating congenital blepharoptosis. Key words: kinds of surgery; children congenital blepharoptosis

A Dynamic Technique for the Treatment of Severe or Recurrent Blepharoptosis: Frontalis-Orbicularis Oculi Muscle Flap Shortening

Background: Severe or recurrent blepharoptosis remains a great challenge to most plastic surgeons. A variety of techniques have been developed according to the function of the levator palpebrae superioris and frontalis muscles. In this study, the frontalis-orbicularis oculi (FOO) muscle flap is designed as an entity to treat severe or recurrent blepharoptosis with satisfactory results. Methods: Between January 1997 and July 2007, FOO muscle flap shortening was applied to correct severe or recurrent blepharoptosis in 29 patients (38 eyelids), aged from 3 to 77 years. There were 11 males and 18 females, with bilateral ptosis in 9 patients. The follow-up period ranged from 10 to 52 months. Results: Twenty-four patients (82%) had good results, with the degree of ptosis less than 2 mm. The remaining 5 patients had fair results, and received readjustment in 2 cases. Conclusion: In our study, fresh cadaver dissection revealed that the frontalis muscle is connected and interdigitated very closely with the orbicularis oculi muscle. Based on the anatomic study and literature review, we suggest that the FOO muscle flap shortening is a good alternative to treat severe or recurrent blepharoptosis.

Safe botulinum toxin type A injection in patients with history of eyelid ptosis

Ptosis is an important side effect of frown correction by botulinum toxin type A (BTX-A). The most likely reason of eyelid ptosis is the diffusion of the toxin to levator palpebrae superioris muscle through orbital septum while the toxin is injected into the corrugator muscle. In this pilot study, to prevent ptosis, we evaluated the efficacy of BTX-A injection at superior middle aspect of the corrugator muscle instead of the common injection site located above the medial eyebrow head. Fifteen patients were selected from those referred to our clinic with history of eyelid ptosis due to previous BTX-A (dysport; Ipsen) injection. They received three injections of BTX-A; 10 U into the procerus muscle and 20 U into the superior middle aspect of each corrugator muscle, instead of injecting into the belly of the corrugator muscles. We observed excellent, good and moderate responses in 66.66%, 13.33% and 20% of our patients 2 weeks post-injection respectively. The outcomes were improved to excellent in the latter two groups by injecting 5 U of BTX-A (dysport; Ipsen) into the contractible corrugator in patients with good and 5 U in each corrugator (total of 10 U) in patients with moderate responses. Employing this method a very satisfactory outcome was obtained while no ptosis was observed. Therefore, we recommend this safe technique for treating patients with a history of eyelid ptosis.

Treatment of Paralytic Lagophthalmos With Gold Weight Implants Covered By Levator Aponeurosis

To describe a technique to treat paralytic lagophthalmos and exposure keratitis with gold weight implants covered by levator aponeurosis. The authors studied a case series of 29 patients who underwent surgical treatment for paralytic lagophthalmos using the technique of gold weight implantation covered by the aponeurosis of the levator palpebrae superioris muscle between June 1997 and December 2006. None had undergone previous surgical treatment. All patients sustained their implants; there were no cases of extrusion, dislocation, or infection. Patients had significant improvement of symptoms, especially exposure keratopathy, with lagophthalmos dimensions decreased from 4 to 5 mm preoperatively to 0.5 mm after surgery. Excellent results were obtained by recessing the levator palpebrae superioris muscle aponeurosis with relaxing incisions and advancing it to overly the gold weight implant completely. Visibility of the implant in the pretarsal upper eyelid surface was minimized, extrusion was avoided, and good eyelid position was obtained.

Accessory levator muscle slips of the levator palpebrae superioris muscle

Accessory levator muscle slips may be associated with congenital eyelid retraction or blepharoptosis. Nevertheless, congenital retraction of the upper eyelid is a poorly defined entity about which little is known. Because of the clinical importance of the accessory levator muscle slip of the levator palpebrae superioris muscle, this study aimed to describe the morphological appearance of this variation in human adult orbits. This study was undertaken in 60 orbits of 30 embalmed adult human cadavers, 17 men and 13 women, between the ages of 38 and 87 years at death. All cadavers were embalmed in 4% formalin solution. Three accessory levator muscle slips of the levator palpebrae superioris muscle were identified. One of these arose laterally from the origin of the levator palpebrae superioris muscle. At its anterior end, it divided into two parts, the main superior and a smaller inferior accessory. The second had an accessory levator fibromuscular slip. It arose medially from the origin of the levator palpebrae superioris and lost its muscular character after a short course. The third arose from the origin of the levator palpebrae superioris as a thin flat muscle. Although many variations of the levator palpebrae superioris muscle have been reported in fetuses, investigation and demonstration of these may be more important in children and adults for ophthalmic surgery. We believe that detailed knowledge regarding the morphological appearance of an accessory levator muscle slip of the levator palpebrae superioris muscle may be useful for successful outcomes in ophthalmic surgery.

The human superior tarsal muscle (Müller’s muscle): a morphological classification with surgical correlations

The superior tarsal muscle (STM) is a smooth muscle that originates from the undersurface of the levator palpebrae superioris muscle (LPSM) and inserts onto the superior tarsal plate (STP) of the upper eyelid. We have performed a morphometrical investigation of the STM in 49 adult human cadavers (34 males, 15 females). Histological analysis has shown a transitional area between the skeletal striated muscle (LPSM) and the adjacent smooth muscle (STM). We propose an original morphological classification based upon the attachment of STM to the upper border of the STP. Accordingly, we describe four patterns of STM. Pattern 1 (P1) consists of STM attachment to the central portion of the STP. Pattern 2 consists of both medial (P2M) STM attachment to both the central and medial regions of the STP and lateral (P2L) STM attachment to both the central and lateral regions of the STP. Pattern 3 (P3) consists of STM attachment along the whole extent of the STP. Pattern 3 was the most frequently observed pattern (63.27%) followed by patterns P2M (24.49%), P2L (8.16%) and P1 (4.08%). P3 was the predominant pattern in males (73.52%), while in females, both patterns P2M (46.66%) and P3 (40.00%) were equally prevalent. The analysis of paired specimens revealed a symmetrical arrangement in 72.20% of all cases, with the remaining cases (27.80%) displaying left-right STM asymmetries. To the best of our knowledge, this is the first description of the STM asymmetries in the medical literature. This innovative classification provides anatomical parameters for interpreting morphological variations of the STM with relevant applications in both plastic surgery and ophthalmology.

Palpebrale Variante des Blepharospasmus – Abgrenzung zur Lidöffnungsapraxie und zur Inhibitionsstörung durch synchrone EMG-Ableitungen

Eyelid movements are mediated mainly by the orbicularis oculi and the levator palpebrae superioris muscles. In blinking they show a strictly reciprocal innervation. Blepharospasm manifests as involuntary eyelid closure, however, there are also a number other diseases resulting in the inability to open the eyelid. We analysed clinical and electromyographical findings in 81 patients with disturbances of eyelid opening. Among these were 63 with tonic or clonic dystonic activity only in the orbicular part of orbicularis oculi muscle, 43 with additional dystonic activity in the palpebral part of orbicularis oculi muscle = idiopathic blepharospasm. Ten showed isolated activity in the palpebral part of orbicularis oculi muscle = palpebral variant of blepharospasm. Four exhibited synchronous activity in the orbicularis oculi and the levator palpebrae superioris muscles = disturbance of the antagonistic inhibition. Another four had no activity in the levator palpebrae superioris muscle while activity in the palpebral part of orbicularis oculi muscle was normal = apraxia of eyelid opening. A distinction is relevant for the therapeutic modality and the exact spot as which to inject botulinum toxin. In apraxia of eyelid opening after manual opening the eyelid remains open up to the next contraction of the orbicularis oculi muscle (Zwickau's eye sign).

Tratamento do lagoftalmo paralítico com a utilização do implante de peso de ouro recoberto pela aponeurose do músculo levantador palpebral

POURPOSE: To demonstrate an improvement in paralytic lagophthalmos surgical treatment complications and aesthetic results by covering the gold weight implants with the levator palpebrae muscle aponeurosis. METHODS:We studied a case series of twenty nine patients presenting idiopatic facial palsy with more than 4 years of clinical evolution, submitted to paralytic lagophthalmos surgical treatment using a modification of the technique of gold weight implantation covered by the aponeurosis of the levator palpebrae superioris muscle (Gladstone, 1996) between June 1997 and December [...]

A Cadaveric Anatomical Study of the Levator Aponeurosis and Whitnall's Ligament

PurposeTo identify the anatomy of the levator aponeurosis (LA) and Whitnall's ligament (WL) in Korean subjects using cadavers.MethodsOrbital exenteration was performed in ten cadavers (20 eyeballs) that had no history of trauma near the eyeball. We observed characteristics of WL (tension, density, and shape) and the relationship between the superior rectus muscle (SR) and the levator palpebrae superioris. We measured the distance from both the eyelid margin and the upper border of the tarsal plate to the insertion of the LA medially, centrally, and laterally.ResultsThe WLs we observed showed several shapes. In 12 eyes, we saw clear, white fibrotic bands, while in four others, we found thin, less taut bands. In four eyes, we were unable to identify the precise shape of the band. The insertions of the LA showed nasal dehiscence in 13 eyes and parallel attachment in seven eyes. The distances from the eyelid margin to the insertion of the LA medially, centrally, and laterally were 8.31 mm, 5.57 mm, and 5.15 mm, respectively. The distances from the upper border of the tarsal plate to the insertion of the LA medially, centrally, and laterally were 2.75 mm, 4.82 mm, and 4.29 mm, respectively.ConclusionsThis study examined the anatomy of WL and the LA in Korean subjects and may be helpful as a reference in levator muscle surgery.

Measurements of Lacrimal Glands from Cadavers, With Descriptions of Typical Glands and Three Gross Variants

Objective: To measure cadaveric human lacrimal glands. Methods: Excised lacrimal glands from 22 male and 23 female embalmed cadavers were stored in embalming fluid. They were then blotted, weighed, and measured using dividers and a digital micrometer. Results: Besides the typical gland (Type I), three gross variants were found. The subencapsulated variant (Type II) has dense connective tissue covering its deep surface. This would prevent the usual horizontal positioning of the lobes relative to the levator palpebrae superioris aponeurosis (lpsa), causing the latter to extend but minimally beneath the free edge of the orbital lobe. Consequently, the gland lies mainly beside the globe and angulated parallel to the lpsa. Its adjacent palpebral lobe lies beneath the latter. The bilayered variant (Type III) has its smaller orbital lobe's deep surface affixed above its large, ovoid palpebral lobe. Most of the gland droops beside the globe except for the edge of its orbital lobe which lies above the edge of the lpsa and beneath which the palpebral lobe's anteromedial portion lies. The macrovariant (Type IV) resembles the typical gland. However, between its big lobes is an unusually large gape for the lpsa. Conclusions: Variant lacrimal glands are common (51.1%). Three types have been identified. The subencapsulated (26.7%) and bilayered (22.2%) types are the more common ones. Only one macrovariant (2.2%) specimen was found. Several dimorphisms exist in the typical and subencapsulated types, specimens from male cadavers being larger.

Reflexive contraction of the levator palpebrae superioris muscle to involuntarily sustain the effective eyelid retraction through the transverse trigeminal proprioceptive nerve on the proximal Mueller's muscle: verification with evoked electromyography

We have proposed a hypothetical mechanism to involuntarily sustain the effective eyelid retraction, which consists of not only voluntary but also reflexive contractions of the levator palpebrae superior muscle (LPSM). Voluntary contraction of fast-twitch fibres of the LPSM stretches the mechanoreceptors in Mueller's muscle to evoke trigeminal proprioception, which induces continuous reflexive contraction of slow-twitch fibres of the LPSM through the trigeminal proprioceptive nerve fibres innervating the mechanoreceptors in Mueller's muscle via the oculomotor neurons, as a tonic trigemino-oculomotor reflex. In the common skeletal mixed muscles, electrical stimulation of the proprioceptive nerve, which apparently connects the mechanoreceptors in muscle spindles to the motoneurons, induces the electromyographic response as the Hoffmann reflex. To verify the presence of the trigemino-oculomotor reflex, we confirmed whether intra-operative electrical simulation of the transverse trigeminal proprioceptive nerve on the proximal Mueller's muscle evokes an electromyographic response in the LPSM under general anaesthesia in 12 patients. An ipsilateral, phasic, short-latency response (latency: 2.8+/-0.3 ms) was induced in the ipsilateral LPSM in 10 of 12 subjects. As successful induction of the short-latency response in the ipsilateral LPSM corresponds to the Hoffmann reflex in the common skeletal mixed muscles, the present study is the first electromyographic verification of the presence of the monosynaptic trigemino-oculomotor reflex to induce reflexive contraction of the LPSM. The presence of the trigemino-oculomotor reflex may elucidate the unexplainable blepharoptosis due to surgery, trauma and tumour, all of which may damage the trigeminal proprioceptive nerve fibres to impair the trigemino-oculomotor reflex.