Levator Palpebrae Research Articles

The functional and histopathologic change in the levator palpebrae superioris and Müller muscle after subconjunctival injection of triamcinolone acetonide.

The aim of this study was to evaluate the functional and histopathologic changes in the levator palpebrae superioris and Müller muscles after subconjunctival injection of triamcinolone acetonide (TA) in rabbits. Twenty-four white New Zealand rabbits were divided into 2 groups. In group A, a subconjunctival injection of 0.5 mL TA (40 mg/mL) was administered to the right eye, whereas a normal saline injection of the same volume was administered to the left eye. In group B, the same procedures were done with a 1.0-mL injection of TA or normal saline into each eyelid. Follow-up was done to evaluate the histopathologic changes in the levator and Müller muscles, changes in the mean transectional area of Müller muscle, and changes in upper-lid height (marginal reflex distance 1) at 1, 2, 4, and 6 weeks after injection. Western blot analyses were used to determine the levels of myosin light chain phosphorylation and α-smooth muscle actin, which are related to the contractility of Müller muscle. No specific changes in marginal reflex distance 1 were noted in either group A or B. No significant histopathologic changes were found in the levator muscles. However, significant thinning of Müller muscle were found, and myosin light chain phosphorylation and α-smooth muscle actin levels were decreased. This was consistent with the histologic changes of Müller muscle observed in rabbits that received a TA injection. These changes were reversible and influenced by the volume of the injection. Subconjunctival injection of TA into the upper eyelids appears to be temporally influential on both the functional and histopathologic changes of Müller muscle in rabbits. This may be explained by the effect of improvement in lid retraction regardless of the minimal specific change observed in the levator muscle.

Co-firing of levator palpebrae and masseter muscles links the masticatory and oculomotor system in humans.

Simultaneous co-firing of the levator palpebrae (LP) and pterygoid muscles were recorded in Marcus Gann Syndrome (MGS) patients in early clinical studies. “Release hypothesis” proposed an intrinsic masticatory oculomotor neural circuit and this kind circuit, which, however, has been observed only in amphibian. On the other hand, congenital miswiring hypothesis has overwhelmed other interpretations. However, the same phenomenon visualized in MGS cases was unveiled in human subjects without any sign of congenital oculomotor disorder. To further study co-firing of the upper eyelid and jaw muscles, we applied non-invasive EMG recording of the upper eyelid and ipsilateral masseter muscle belly in nine healthy volunteers. LP activity was determined initially by looking upward and active retraction of upper eyelid with head fixed. Then, dual channel inputs from upper eyelid and masseter muscle was recorded during tooth occlusion motivated by isometric masseter muscle contraction without jaw and face moving. The EMG recorded from upper eyelid when the subjects retracted eyelid with head fixed exhibited the same pattern as that collected during tooth occlusion, but the pattern was completely different from EMG of active eye closure. This reflects tooth occlusion evoked LP activity. Then, simultaneous co-firing of the LP and masseter muscle was recorded simultaneously during tooth occlusion without jaw movement. Finally, the aforementioned co-firing was recorded when the subjects conducted rhythmic occlusion and synchronous EMG from both muscles was acquired. In conclusions, humans may also have an intrinsic masticatory oculomotor circuit and release hypothesis may apply, at least, to some cases of MGS.

Transmitter inputs to different motoneuron subgroups in the oculomotor and trochlear nucleus in monkey.

In all vertebrates the eyes are moved by six pairs of extraocular muscles enabling horizontal, vertical and rotatory movements. Recent work showed that each extraocular muscle is controlled by two motoneuronal groups: (1) Motoneurons of singly-innervated muscle fibers (SIF) that lie within the boundaries of motonuclei mediating a fast muscle contraction; and (2) motoneurons of multiply-innervated muscle fibers (MIF) in the periphery of motonuclei mediating a tonic muscle contraction. Currently only limited data about the transmitter inputs to the SIF and MIF motoneurons are available. Here we performed a quantitative study on the transmitter inputs to SIF and MIF motoneurons of individual muscles in the oculomotor and trochlear nucleus in monkey. Pre-labeled motoneurons were immunostained for GABA, glutamate decarboxylase, GABA-A receptor, glycine transporter 2, glycine receptor 1, and vesicular glutamate transporters 1 and 2. The main findings were: (1) the inhibitory control of SIF motoneurons for horizontal and vertical eye movements differs. Unlike in previous primate studies a considerable GABAergic input was found to all SIF motoneuronal groups, whereas a glycinergic input was confined to motoneurons of the medial rectus (MR) muscle mediating horizontal eye movements and to those of the levator palpebrae (LP) muscle elevating the upper eyelid. Whereas SIF and MIF motoneurons of individual eye muscles do not differ numerically in their GABAergic, glycinergic and vGlut2 input, vGlut1 containing terminals densely covered the supraoculomotor area (SOA) targeting MR MIF motoneurons. It is reasonable to assume that the vGlut1 input affects the near response system in the SOA, which houses the preganglionic neurons mediating pupillary constriction and accommodation and the MR MIF motoneurones involved in vergence.

Isolated nuclear III nerve paresis secondary to neurocysticercosis showing spontaneous clinical improvement.

Sir, We wish to present a case of isolated nuclear IIIrd nerve paresis secondary to neurocysticercosis (NCC) showing spontaneous clinical improvement. Isolated third cranial nerve palsy is rare in NCC. A 14-year-old male child of Nepali origin presented with diplopia for 6 days in left lateral gaze and drooping of his upper eyelids in both eyes. The complaints were insidious in onset, non-progressive simultaneous in both eyes with no diurnal fluctuation. Rest of his present and past medical history was not significant. He had history of pork consumption. His general physical examination and systemic examination including neurological examination was unremarkable. His visual acuity was 6/6 OU with increased wrinkling on forehead. He had severe neurological ptosis in both eyes with poor levator palpebrae superioris (LPS) action with no Marcus Gunn phenomenon and no sign s/o fatigueability. He also had an exotropia of about 15 degree and mild paresis of elevation of eyeball in right eye maximum in lateral gaze. He had mild paresis of his right medial rectus with end gaze nystagmus in left gaze. Rest of the ophthalmological examination was unremarkable including papillary reactions. Diplopia charting showed horizontal diplopia in all gaze positions with maximum difference in left lateral gaze positions [Figure 1]. While waiting for his investigation reports his sign and symptoms showed spontaneous clinical improvement. His magnetic resonance imaging (MRI) showed a solitary ring-enhancing lesion in the pre-aqueductal region of mid brain of size 0.72 × 0.68 cm involving IIIrd nerve nucleus with peri lesional edema [Figure 2]. His lumbar puncture was done and it revealed CSF protein levels 60 and it also showed 9 white blood cells mainly lymphocytes. ADA levels in his CSF were within normal limit. His serology revealed positive IgG levels for taenia solium (1.13 U/ml) by ELISA. In the light of the above findings the patient was diagnosed as a case of nuclear third nerve paresis secondary to NCC of brainstem. After consultation with Department of Neurology the patient was put on oral albendazole and prednisolone. He was continuously followed up with no similar episodes till 1 year after. Figure 1 (a) Ptosis in both eyes. (b) Paresis of Medial rectus in right eye. (c) Paresis of elevation in right eye. (d-f) Respective improvement Figure 2 Transverse section in MRI showing solitary ring enhancing lesion in the pre-aqueductal region of mid brain of size 0.72 × 0.68 cm involving IIIrd nerve nucleus with peri lesional edema NCC is the most common parasitic infestation of the nervous system.[1] Globally, NCC is endemic in Central and South America, sub-Saharan Africa, and in some regions of the Far East, including the Indian subcontinent, Indonesia, and China, reaching an incidence of 3.6% in some regions.[1] Del Brutto et al. have suggested diagnostic criteria for NCC.[2] In our case these criteria were fulfilled for probable diagnosis of NCC. It usually presents with seizures. Other various CNS clinical manifestations include headache, hydrocephalus, chronic meningitis, focal neurological deficits, dementia and psychiatric manifestations.[3] Involvement of third nerve is rare especially due to a parenchymal lesion.[4] Fluctuation in perilesional edema was probably responsible for spontaneous clinical recovery in our patient. The lesion in such nuclear third nerve paresis involves the central caudal nucleus (CCN), which is a small subgroup of oculomotor nucleus containing subnucleus for levator palpebrae superioris.[5] Involvement of this nucleus results in complete, bilateral ptosis. We propose a more detailed evaluation of patients with fluctuating ptosis. In those patients where ptosis is restricted to ocular muscle without any other neuromuscular involvement, cranial imaging needs to be done, preferably MRI of the brain with contrast studies that may show lesions in the midbrain.

Detailed anatomy of the transverse superior fascial expansion of the upper eyelid.

This study was designed to elucidate the detailed anatomy of the transverse superior fascial expansion (TSFE) and its relationship to the superior rectus muscle (SRM) and the levator palpebrae superioris (LPS). In this cohort study, 46 eyes of 23 cadavers were observed macroscopically. Dissection from the SRM origin to its insertion was performed, and the width, length, and tensile strength of the TSFE were determined. The TSFE was located between the LPS and SRM. It originated at the surface of the SRM, 32.75 ± 4.40 mm from the origin of the SRM, and extended anteriorly. The TSFE firmly adhered to the SRM surface, 1.53 ± 0.47 mm medially and 1.19 ± 0.19 mm laterally, extended upwards and anteriorly, and inserted to the under surface of the LPS. The TSFE width was 6.70 ± 1.17 mm at the origin site on the SRM surface and 11.42 ± 6.70 mm at the insertion site on the LPS under the surface. Its total length was 11.67 ± 0.87 mm medially and 11.55 ± 0.94 mm laterally The TSFE was first encountered 11.49 ± 1.17 mm laterally and 11.57 ± 1.27 mm medially from the SRM insertion on the SRM's anterior surface. The tensile strength of the TSFE was significantly greater than that of the intermuscular fascia between the SRM and LPS (9.74 ± 4.53 N vs 3.02 ± 1.85 N, P =0.001). This study provides a good understanding of the TSFE structures conducive to performing SRM surgery.

Stress-relaxation and fatigue behaviour of synthetic brow-suspension materials

Ptosis describes a low position of the upper eyelid. When this condition is due to poor function of the levator palpebrae superioris muscle, responsible for raising the lid, “brow-suspension” ptosis correction is usually performed, which involves internally attaching the malpositioned eyelid to the forehead musculature using brow-suspension materials. In service, such materials are exposed to both rapid tensile loading and unloading sequences during blinking, and a more sustained tensile strain during extended periods of closure. In this study, various mechanical tests were conducted to characterise and compare some of commonly-used synthetic brow-suspension materials (Prolene®, Supramid Extra® II, Silicone rods (Visitec® Seiff frontalis suspension set) and Mersilene® mesh) for their time-dependent response. At a given constant tensile strain or load, all of the brow-suspension materials exhibited stress-relaxation or creep, with Prolene® having a statistically different relaxation or creep ratio as compared with those of others. Uniaxial tensile cyclic tests through preconditioning and fatigue tests demonstrated drastically different time-dependent response amongst the various materials. Although the tests generated hysteresis force–strain loops for all materials, the mechanical properties such as the number of cycles required to reach the steady-state, the reduction in the peak force, and the cyclic energy dissipation varied considerably. To reach the steady-state, Prolene® and the silicone rod required the greatest and the least number of cycles, respectively. Furthermore, the fatigue tests at physiologically relevant conditions (15% strain controlled at 6.5Hz) demonstrated that the reduction in the peak force during 100,000 cycles ranged from 15% to 58%, with Prolene® and the silicone rod exhibiting the greatest and the least value, respectively.Many factors need to be considered to select the most suitable brow-suspension material for ptosis correction. These novel data on the mechanical time-dependent performance could therefore help to guide clinicians in their decision-making process for optimal surgical outcome.

Eyelid closure in embryogenesis is required for ocular adnexa development.

Mammalian eye development requires temporary fusion of the upper and lower eyelids in embryogenesis. Failure of lid closure in mice leads to an eye open at birth (EOB) phenotype. Many genetic mutant strains develop this phenotype and studies of the mutants lead to a better understanding of the signaling mechanisms of morphogenesis. The present study investigates the roles of lid closure in eye development. Seven mutant mouse strains were generated by different gene ablation strategies that inactivated distinct signaling pathways. These mice, including systemic ablation of Map3k1 and Dkk2, ocular surface epithelium (OSE) knockout of c-Jun and Egfr, conditional knockout of Shp2 in stratified epithelium (SE), as well as the Map3k1/Jnk1 and Map3k1/Rhoa compound mutants, all exhibited defective eyelid closure. The embryonic and postnatal eyes in these mice were characterized by histology and immunohistochemistry. Some eye abnormalities, such as smaller lens in the Map3k1-null mice and Harderian gland hypoplasia in the Dkk2-null mice, appeared to be mutant strain-specific, whereas other abnormalities were seen in all mutants examined. The common defects included corneal erosion/ulceration, meibomian gland hypoplasia, truncation of the eyelid tarsal muscles, failure of levator palpebrae superioris (LPS) extension into the upper eyelid and misplacement of the inferior oblique (IO) muscle and inferior rectus (IR) muscle. The muscle defects were traced to the prenatal fetuses. In addition to providing a protective barrier for the ocular surface, eyelid closure in embryogenesis is required for the development of ocular adnexa, including eyelid and extraocular muscles.

Vertical Diplopia and Ptosis from Removal of the Orbital Roof in Pterional Craniotomy

To describe a newly recognized clinical syndrome consisting of ptosis, diplopia, vertical gaze limitation, and abduction weakness that can occur after orbital roof removal during orbito-zygomatic-pterional craniotomy. Case series. Eight study patients (7 women), 44 to 80 years of age, with neuro-ophthalmic symptoms after pterional craniotomy. Case description of 8 study patients. Presence of ptosis, diplopia, and gaze limitation. Eight patients had neuro-ophthalmic findings after pterional craniotomy for meningioma removal or aneurysm clipping. The cardinal features were ptosis, limited elevation, and hypotropia. Three patients also had limitation of downgaze and 2 patients had limitation of abduction. Imaging showed loss of the fat layers that normally envelop the superior rectus and levator palpebrae superioris. The muscles appeared attached to the defect in the orbital roof. Ptosis and diplopia developed in 2 patients despite Medpor titanium mesh implants. Deficits in all patients showed spontaneous improvement. In 2 patients, a levator advancement was required to repair ptosis. In 3 patients, an inferior rectus recession using an adjustable suture was performed to treat vertical diplopia. Follow-up a mean of 6.5 years later revealed that all patients had a slight residual upgaze deficit, but alignment was orthotropic in primary gaze. After pterional craniotomy, ptosis, diplopia, and vertical gaze limitation can result from tethering of the superior rectus-levator palpebrae superioris complex to the surgical defect in the orbital roof. Lateral rectus function sometimes is compromised by muscle attachment to the lateral orbital osteotomy. This syndrome occurs in approximately 1% of patients after removal of the orbital roof and can be treated, if necessary, by prism glasses or surgery.

Sudden onset diplopia in an elderly male patient : answer

Brain diffusion-weighted imaging revealed a small hyperintense lesion involving the median dorsal midbrain (Fig. 1). Aspirin and clopidogrel were prescribed. He was discharged 8 days after onset, at which point his diplopia was slightly improved. Binocular double vision suggests the dysfunction of extraocular muscles, the neuromuscular junction, cranial nerves, cranial nerve nuclei, or internuclear and supranuclear connections [1]. Accurate localization of the underlying lesion is the first step towards the correct diagnosis. Each extraocular muscle is innervated by the corresponding cranial nerve, which originates from the individual cranial nerve nucleus. In complete oculomotor nerve palsy, there is ptosis due to the dysfunction of the levator palpebrae superioris muscle. The eye is deviated down and out, with impaired elevation, depression, and adduction. Pupil involvement usually indicates a compressive lesion, while sparing of the pupil is more likely due to ischemia [1]. The oculomotor nucleus is a paired structure that is located in the midbrain, adjacent to the medial longitudinal fasciculus (MLF) and reticular formation, ventral to the aqueduct of Sylvius and the fourth ventricle. The oculomotor nucleus lesion typically causes ipsilateral ophthalmoparesis and pupil dilatation with bilateral impairment of ocular elevation and bilateral ptosis. Isolated weakness of a single muscle is possible with an oculomotor nucleus lesion and isolated bilateral oculomotor nuclear palsy is extremely rare [2]. Classic signs of internuclear ophthalmoplegia (INO) are the impairment of adduction of the ipsilateral eye and the preservation of abduction of the contralateral eye when the patient tries to gaze in the contralateral direction [3]. It is induced by a lesion involving the MLF in the brainstem. One-and-a-half syndrome consists of lateral gaze palsy in one direction and INO in the other direction with a contralateral gaze. It occurswith lesions in the dorsal pontine tegmentum that impair both the ipsilateral paramedian pontine reticular formation or the abducens nucleus and the ipsilateralMLF.

Serial reconstruction of anophthalmic orbits with ‘bag-shaped’ flaps

The author's goal was to present an approach for serial surgical reconstruction of anophthalmic orbits with 'bag-shaped' flaps and cartilage transplantation. A review was performed of 53 patients who underwent serial physiological orbital reconstruction between 2006 and 2013. Orbital reconstruction was performed serially in stages, including "bag-shaped" flap transplantation, medial and lateral canthoplasty, tarsus reconstruction, and improvement of the strength of the levator palpebrae superior muscles. Curative effects were evaluated by the surgeons and patients jointly. Among the total of 53 cases, the curative effects were assessed as excellent in 28 patients, good in 17 patients, moderate in 6 patients, and poor in 2 patients. Two cases suffered necrosis of the bag-shaped flap, which was remedied with a frontal island flap and skin grafting; 4 cases experienced shallowness of the lower fornix, of which three were remedied by deepening of the lower fornix and the other by lower eyelid suspension. The appearance of the reconstructed eye socket was acceptable, natural and persistent. This procedure offers staged and serial reconstruction of anophthalmic orbits, according to the orbital shape and the volume loss of the orbital soft tissue. It is an ideal approach to reconstruct eye sockets, with a high survival rate of the flaps, acceptable appearance of the reconstructed eye socket, and stable depth of the upper and lower eyelid fornices.

Acute ptosis as the sole presenting symptom of a pulmonary adenocarcinoma

Although rare, secondary metastasis to the orbit is a wellrecognized clinical entity with a prevalence of 1–13% of all orbital tumours [1]. The most common aetiology of orbital metastasis among men are lung carcinomas and in women, breast carcinomas [2]. Presentations of orbital metastases are varied including eye pain, diplopia, visual impairment, proptosis, ocular motility disorders with possible palpable masses at the orbit [3]. It is rare for blepharoptosis to be the sole orbital metastatic presentation involving only the levator palpebrae superioris muscle [4].

Embryology of extraocular muscles : A new vision

AbstractPurpose To describe the embryology of extraocular muscles, through a 3D viewing algorithm, from Carnegie stage XVII to Carnegie stage XXIII (41st‐57th day of development).Methods The work consisted of a scanning and a data processing reconstruction of embryonic histological material. Material came from anatomical universities collections. 12 embryos were selected, and 7 were dedicated to muscle study (from 14.5mm to 54.5mm). This data processing has allowed a study in three spatial planes.Results From Carnegie stage XVII, all extraocular muscles are in place, including levator palpebrae. The study in 3 planes makes their individualization easier. Gilbert (Carnegie Institution) described the origin of inferior rectus and inferior oblique by a common primordium, however from the stage XVII the two muscles are clearly separated. The decussation of the superior oblique is seen from the stage XIX, the trochlea appears at stage XXII. Our work also demonstrates the nerves : optic, oculomotor, trochlear, trigeminal and abducens. The junctions between nerve and muscle are put in evidence, especially for the lower branch of the oculomotor nerve.Conclusion This new study tool has resulted in explicit images of the development of extraocular muscles in the embryonic period. It helped to provide details with respect to the work already established by the Carnegie Institution.

Superior rectus underaction following botulinum toxin injection to induce protective upper eye lid ptosis – a comparative study of two techniques

Background: Botulinum toxin A (BTXA) injection to the levator palpebrae superioris muscle to induce a protective ptosis can adversely cause reduced upgaze due to diffusion of BTXA to the superior rectus muscle.Purpose: To compare the incidence of reduced upgaze in trascutaneous versus transconjunctival administration of BTXA to induce protective ptosis in patients with exposure keratopathy due to facial nerve palsy.Methods: All patients included in this study suffered from acute exposure keratopathy and they all required chemodenervation of the levator muscle to induce a protective ptosis. Patients in group A received BTXA (Dysport) transcutaneously though the upper eyelid skin crease. Patients in group B received BTXA (Dysport) into the subconjunctival space at the superior border of the tarsal plate of the upper eyelid transconjunctivally. All subjects were closely monitored after BTXA injection and during each follow-up assessment the upper eyelid was lifted in order to uncover the effects on ocular motility. All patients had a follow-up of at least 1 year following injection of BTXA for their facial nerve palsy and its complications.Results: In group A, 20 patients were included. Reduced upgaze occurred in 9 patients (45%). Five required treatment with a Fresnel prism or ocular occlusion to avoid intractable diplopia. There were 15 patients in Group B, and only 2 of them developed post-treatment superior rectus underaction. One of these patients resolved spontaneously and the other patient required treatment with a spectacle-mounted Fresnel prism for diplopia. The difference in incidence of reduced upgaze between the 2 techniques was statistically significant (Fisher’s exact test, P = 0.0493).Conclusion: Injecting BTXA to induce protective ptosis via a transconjunctival supratarsal route was significantly less likely to induce superior rectus underaction than when given via the transcutaneous route.

Transient and Isolated Neurogenic Blepharoptosis After Medial Orbital Wall Reconstruction

Neurogenic blepharoptosis related to orbital surgery is very rare and only 1 report was published in the literature. This report presents 1 case of transient and isolated neurogenic blepharoptosis after medial orbital wall reconstruction. A 12-year-old male patient who suffered from periorbital trauma visited our hospital with right periorbital pain. During the physical examination, mild ecchymosis and eyelid edema were reported; however, there were no signs of either limitation of ocular motion or anisocoria. On the orbital CT images, a 17 mm × 20 mm-sized medial orbital bony defect was observed and the medial rectus muscle and orbital fat were herniated. The operation was performed 12 days after injury and the transcaruncular approach was used to reach the medial orbital wall. After the operation, he had right side blepharoptosis with mild eyelid edema and ecchymosis. However, ocular movement was normal and there were no signs of anisocoria. He did not receive any additional medication for blepharoptosis and was discharged 3 days postoperation. By the ninth day of postoperative recovery, the patient still suffered from right blepharoptosis with no levator palpebrae superioris muscle function. We prescribed a low dose of oral corticosteroid and the patient was monitored on a weekly basis. Finally, he recovered completely with normal symmetric eyelid position and levator function.

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.

Embryology of extraocular muscles: a new vision (923.7)

Purpose : To describe the embryology of extraocular muscles through 3D viewing algorithm from Carnegie stage XVII to Carnegie stage XXIII (41st‐57th day of development).Materials and Method : The work consisted of a scanning and a data processing reconstruction of embryonic histological material. Material came from anatomical universities collections. 12 embryos were selected, and 7 were dedicated to muscle study (from 14.5mm to 54.5mm). This data processing has allowed a study in three spatial planes.Results : From stage XVII, all extraocular muscles are in place, including levator palpebrae. The study in 3 planes makes their individualization easier. Gilbert (Carnegie Institution) described the origin of inferior rectus and inferior oblique by a common primordium, however from the stage XVII the two muscles are clearly separated. The decussation of the superior oblique is seen from the stage XIX, the trochlea appears at stage XXII. Our work also demonstrates the nerves : optic, oculomotor, trochlear, trigeminal and abducens. The junctions between nerve and muscle are found, especially for the lower branch of the oculomotor nerve.Conclusion : This new study tool has resulted in explicit images of the development of extraocular muscles in the embryonic period. It helped to provide details with respect to the work already established by the Carnegie Institution.

Subconjunctival cysticerscosis with involvement of superior muscle complex - a case report

Cysticercosis is a parasitic infestation caused by cysticercus cellulose. Ocular and adnexal cysticercosis represents 13% to 46% of systemic disease. There are different modes of presentation of ocular cysticercosis. Case: Here we report a case with the left upper eyelid ptosis. On ocular examination, there was presence of a cystic yellowish mass of size of the eye ball in the upper palpebral sub-conjunctiva along with dystropia and limitation of extraocular movements in dextroelevation. Complete surgical excision of the cyst was achieved through splitting of the left upper eyelid. There was presence of sub-conjunctival cyst along with involvement of levator palpebral superioris (LPS) and superior rectus (SR) muscle. Histopathological examination of the cyst showed features suggestive of cysticercosis. The patient was symptomatically better postoperatively. He was commenced on oral prednisolone 1mg/kg and oral albendazole 400 mg for 28 days. Conclusion: Cysticercosis should be considered in cases of inflammatory swelling of subconjunctival space especially in people with poor personal and community hygiene. DOI: http://dx.doi.org/10.3126/hren.v11i3.9659 Health Renaissance 2013;11(3):293-296

Delineation of motoneuron subgroups supplying individual eye muscles in the human oculomotor nucleus

The oculomotor nucleus (nIII) contains the motoneurons of medial, inferior, and superior recti (MR, IR, and SR), inferior oblique (IO), and levator palpebrae (LP) muscles. The delineation of motoneuron subgroups for each muscle is well-known in monkey, but not in human. We studied the transmitter inputs to human nIII and the trochlear nucleus (nIV), which innervates the superior oblique muscle (SO), to outline individual motoneuron subgroups. Parallel series of sections from human brainstems were immunostained for different markers: choline acetyltransferase combined with glutamate decarboxylase (GAD), calretinin (CR) or glycine receptor. The cytoarchitecture was visualized with cresyl violet, Gallyas staining and expression of non-phosphorylated neurofilaments. Apart from nIV, seven subgroups were delineated in nIII: the central caudal nucleus (CCN), a dorsolateral (DL), dorsomedial (DM), central (CEN), and ventral (VEN) group, the nucleus of Perlia (NP) and the non-preganglionic centrally projecting Edinger–Westphal nucleus (EWcp). DL, VEN, NP, and EWcp were characterized by a strong supply of GAD-positive terminals, in contrast to DM, CEN, and nIV. CR-positive terminals and fibers were confined to CCN, CEN, and NP. Based on location and histochemistry of the motoneuron subgroups in monkey, CEN is considered as the SR and IO motoneurons, DL and VEN as the B- and A-group of MR motoneurons, respectively, and DM as IR motoneurons. A good correlation between monkey and man is seen for the CR input, which labels only motoneurons of eye muscles participating in upgaze (SR, IO, and LP). The CCN contained LP motoneurons, and nIV those of SO. This study provides a map of the individual subgroups of motoneurons in human nIII for the first time, and suggests that NP may contain upgaze motoneurons. Surprisingly, a strong GABAergic input to human MR motoneurons was discovered, which is not seen in monkey and may indicate a functional oculomotor specialization.

Isolated Traumatic Neurogenic Ptosis With Delayed Recovery

To describe the entity of isolated neurogenic ptosis due to presumed tractional injury to the nerve of innervation of the levator palpebrae superioris, with recovery occurring over a period up to 6 months. Retrospective case review. Three cases of presumed neurapraxic injury to the nerve of innervation to the levator palpebrae superioris are described. Two cases had a clear history of traction to the upper eyelid. There was no evidence of damage to other extraocular muscles or their nerves of innervation in 2 cases and mild transient superior rectus underaction in 1. Maximal recovery occurred over a period of up to 6 months. Traumatic neurapraxic injury to the nerve of innervation to the levator palpebrae superioris may occur in certain types of upper eyelid injury, most notably when there is significant forward traction applied to the upper eyelid. Although recovery may occur within weeks, as previously described, this series illustrates that recovery may take up to 6 months.

Double Fold Affected by Levator Function in Simultaneous Double Eyelid Blepharoplasty with Blepharoptosis Surgery

Purpose: To evaluate height and symmetry of double folds following simultaneous levator palpebral muscle resection and double eyelid blepharoplasty for correction of blepharoptosis. Methods: We retrospectively studied 400 eyes of 286 patients who underwent simultaneous surgeries for double eyelid construction and correction of blepharoptosis from January 2006 to December 2011. All the patients were divided into three groups based on levator palpebrae muscle function: group A consisted of 82 eyes whose Levator Function Test (LFT) was 5 cm or less, group B consisted of 115 eyes whose LFT was between 5 and 10 cm, group C consisted of 203 eyes whose LFT was over 10 cm. For each group, we evaluated the preoperative marginal reflex distance 1 (MRD1), surgical methods, the postoperative height and symmetry of the double folds, and additional operations for correcting blepharoptosis. Results: Blepharoptosis surgery was performed in all groups by simultaneous levator resection and double eyelid blepharoplasty in all groups. Postoperative asymmetric double fold was the most common outcome observed in the poor levator function group A. Blepharoptosis under-correction was the most common cause of asymmetric double fold and its occurrence was statistically different between the three groups. The other causes were skin redundancy, brow elevation, double fold loosening, and blepharoptosis over-correction. Conclusions: The height of a double eyelid can be changed postoperatively by changing levator palpebrae muscle function. In cases of poor levator function, the levator palpebrae muscle is positioned slightly lower than the normal double fold. This condition may result in further relapse or recurrence in the poor levator function group. Also, levator function should be considered among the diverse factors that determine the height of the double fold. J Korean Ophthalmol Soc 2014;55(11):1579-1583