Neurogenic Ptosis Research Articles

Prévalence du réflexe de Charles Bell et évolution postopératoire dans la chirurgie du ptosis aponévrotique

Background: Ptosis surgery is common in oculoplastics, and its most threatening complication is corneal ulceration. Several factors have been associated with postoperative corneal disorders, such as the strength of the orbicularis muscle, the type of surgery performed, and theBell’s phenomenon reflex (BPR). The goal of this study was to investigate the prevalence of physiological BPR, absence of BPR, and presence of inverse BP in patients undergoing surgery for aponeurotic ptosis. The changes in the BPR during the postoperative course as well as the occurrence of corneal complications were also studied.Materials and Methods: A retrospective study was conducted at the University Hospital of Nice from January 2018 to December 2023. Patients operated on for aponeurotic ptosis were included. Patients with myogenic or neurogenic ptosis or with missing data were excluded. Data were recorded preoperatively and one month postoperatively and included: eyelid height, orbicularis muscle strength, prevalence of BPR, lack of BPR, inverse BPR, and postoperative corneal ulcer.Results: 98 eyelids of 57 patients were included over the study period. Preoperatively, the prevalence of physiological BPR, no BPR, and inverse BPR were 71.4%, 18.4%, and 10.2%, respectively. At one month postoperatively, 30.6% of patients experienced a change in BPR (p=0.004). The postoperative prevalence of BPR, no BPR, and inverse BPR were 77.5%, 17.4%, and 5.1%, respectively. The rate of postoperative corneal ulcers was 1.02%.Conclusion: Among patients operated on for aponeurotic ptosis, the prevalence of physiological BPR was 71.4% preoperatively. Approximately one-third of patients experienced a change in BPR one month postoperatively with a postoperative physiological BPR prevalence of 77.5%. The rate of corneal complications was low.

Clinical Characteristics And Success Of Ptosis Surgery At Indonesia National Eye Center Cicendo Eye Hospital During January 2016 – December 2020

ABSTRACT Ptosis is defined as drooping of the upper eyelid. Unilateral or bilateral ptosis can affect appearance and visual function, both of which can negatively impact quality of life. It may be congenital or acquired, determined by the timing of onset. To describe clinical characteristics and surgical outcomse in ptosis correction surgery at Indonesia National Eye Centre, Cicendo Eye Hospital. This is a descriptive-retrospective study, medical records of patients who was admitted to Indonesia National Eye Centre, Cicendo Eye Hospital, from January 2016 to December 2020 with diagnosis of eyelid ptosis were included in this study. From total of 189 patients (209 eyes) in this study, there were 41,8% male and 58,2% female patients with median age 22 years at the first time of visit. Most of the patients had unilateral ptosis (89,5%), and 10,5% had unilateral ptosis. According to the etiology of ptosis, 34,2% eyes were neurogenic ptosis. Degree of ptosis were severe in 70,9% eyes and most patients had fair levator function. Success rate were more than 95% in ptosis patient who underwent surgery. Majority of ptosis patient in Indonesia National Eye Centre, Cicendo Eye Hospital were caused by neurogenic followed by mechanical, traumatic, aponeurotic, myogenic, and pseudoptosis. Female patients were more common than male patients and median age at the first time visit were during second decade of life. Surgical outcome in ptosis tend to have high clinical success rates. Keywords: Characteristic, Outcome, Ptosis, Surgery

Levator Resection in Neurogenic Ptosis Oculi Sinistra et causa Third Nerve Paresis + Type II Diabetes: A Case Report

Introduction : Neurogenic ptosis is abnormal position of the upper eyelid caused by dysfunction or damage to the oculomotor or sympathetic nerves supplying the eyelids. Third nerve palsy (35.7%) is the most common cause among others. We report a case of neurogenic ptosis managed surgically by levator resection.
 Case Illustration : A 67-year-old male complained of drooping left upper eyelid, getting worse in 7 months. He had history of falling off motorcycle 6 months ago. Clinical histories of hypertension and diabetes mellitus were found. Right and left eyelids measurements in millimeter showed horizontal palpebral fissure (HPF) 28/26, vertical palpebral fissure (VPF) 6/3, margin reflex distance 1 (MRD1) 2/-2, margin reflex distance 2 (MRD2) 6/5, margin limbal distance (MLD) 8/4, and levator function (LF) 8/3. Bell’s phenomenon was negative in both eyes. Ice pack test was negative. There were ocular movement restriction in his left eye. Patient underwent a maximum levator resection and had better levator function after 3 weeks follow up.
 Discussion : Neurogenic ptosis caused by third nerve injury is associated with microvascular ischemia such as diabetes mellitus and hypertension. Operative management is carried out after 3 to 6 months observation. Evaluation of levator function allows the clinician to correctly classify the degree and type of ptosis. Maximal levator resection is the treatment of choice for ptosis with poor levator function.
 Conclusion : Although various surgical techniques have been developed, ptosis correction should be performed according to the indications and clinical condition of the patient.

Etiology of congenital ptosis - literature review

Karolina Ridikaitė1, Dovilė Bučaitė1, Dalia Jarušaitienė1, 2 1Lithuanian University of Health Sciences, Academy of Medicine, Faculty of Medicine, Kaunas, Lithuania 2Lithuanian University of Health Sciences Kauno klinikos, Department of Ophthalmology, Kaunas, Lithuania Abstract Background. Ptosis is abnormal drooping of the upper eyelid (> 2 mm). It is divided into two categories: congenital ptosis, which is present at birth, and acquired ptosis. The pathogenesis of congenital ptosis is thought to be due to a disorder of muscle development and damage to the innervation of the muscles. In contrast, there is currently no precise description of the pathogenesis of congenital eyelid ptosis. Aim. To present the main clinical manifestations of congenital ptosis, based on the available scientific literature. Material and methods. A literature review was conducted in the “PubMed” database using the terms “congenital ptosis” and “myogenic congenital ptosis” and “neurogenic congenital ptosis” from 2010 to 2023. Inclusion criteria was represented by articles relevant to these searches. Results. 1) Myogenic ptosis occurs when the development of the muscle responsible for elevating the upper eyelid is affected and replaced with other tissues. The condition is commonly seen as isolated congenital ptosis or blepharophimosis-ptosis-inverse epicanthal syndrome. 2) Neurogenic ptosis is characterized by an interruption in the nerve signals that control the muscles responsible for elevating the upper eyelid. The condition commonly presents as congenital fibrosis of the extraocular muscles, Marcus Gunn syndrome, Duane syndrome, Moebius syndrome, hereditary congenital facial paresis, Horner’s syndrome and congenital III cranial nerve palsy. Conclusions. Myogenic and neurogenic ptosis are most commonly described in the literature, with a higher prevalence in childhood. In contrast, the underlying mechanism of etiopathogenesis remains unclear. Keywords: congenital ptosis, myogenic congenital ptosis, neurogenic congenital ptosis Full article https://doi.org/10.53453/ms.2023.5.12

Etiology and clinical characteristics of acquired ptosis

Objective: To evaluate the demographics, etiology composition, clinical characteristics and surgical outcomes of acquired ptosis patients. Methods: Retrospective case-series study. The clinical records of 176 consecutive patients (312 eyes) with acquired ptosis were reviewed from January 2009 to December 2018 in the Ophthalmology Department of Tianjin Medical University General Hospital. The demographics, etiology composition, clinical characteristics, surgical strategies and outcomes were analyzed. Results: There were 59 male (33.5%) and 117 female (66.5%) patients suffering acquired ptosis, with an average age of (64±7) years. The disease was bilateral in 136 cases and unilateral in 40 cases. There were four etiological components of acquired ptosis: 145 cases (82.4%) of aponeurotic ptosis, 17 cases (9.6%) of neurogenic ptosis, 10 cases (5.7%) of myogenic ptosis and 4 cases (2.3%) of traumatic ptosis. The clinical characteristics of acquired ptosis varied significantly depending on etiology. Ptosis surgeries were performed on 152 cases (279 eyes), and the success rate was 92.1% (140/152). Surgical procedures included levator aponeurosis surgeries on 148 cases (275 eyes), frontal muscle suspensions on 2 cases (2 eyes) and conjunctival-Müller's ectomies on 2 cases (2 eyes). Conclusions: Acquired ptosis is more likely to occur in senile and female populations with bilateral eyelids involved mostly. Aponeurotic ptosis is the predominant type of acquired ptosis. The treatment is performed according to the clear etiological diagnosis based on clinical features, and operations are efficient for most patients with acquired ptosis. (Chin J Ophthalmol, 2021, 57: 844-849).

Etiology, management of ptosis in working age group and its surgical outcome – A prospective study

To study the etiology of ptosis among 20 - 50 years of age and analyse the management and surgical outcomes of various types of ptosis using different surgical modalities. This prospective study was conducted at Tertiary Eye Care centre in Chennai from July 2018 - June 2019.It included all patients with ptosis between the age of 20 - 50 years after excluding vascular malformations and malignant tumours of the lid. Here all variables are described with frequency distribution and displayed using percentage. Incidence of congenital ptosis was 11 cases (37%), aponeurotic ptosis 8 cases (26%), myogenic ptosis 4 cases (13%), neurogenic ptosis 3 cases (10%), mechanical ptosis. 2 cases (7%), post traumatic ptosis 2 cases (7%). 70% were males and the remaining 30% were females. Among 30 cases, 23 patients had unilateral and 7 patients had bilateral ptosis. Moderate ptosis (3-4mm) (46.7%) formed a major composition of our study shortly followed by severe ptosis (43.3%). Out of 30 cases, 9 cases were managed medically (30%) and surgical intervention was required in 21 cases (70%). Out of 7 bilateral ptosis, 2 cases were managed medically and 5 cases needed surgical intervention. Complications following frontalis sling were under correction (27.3%) in 3 cases followed by mild corneal exposure keratitis (9.1%) in one patient. Complications following levator advancement were under correction in one case (12.5%) and mild lid peaking in one case (12.5%). Among 2 cases of mechanical ptosis, one was squamous papilloma and other was a large chalazion. Out of 4 myogenic cases 3 cases were due to myasthenia and the other diagnosed to have CPEO. 2 cases of traumatic ptosis were due to traumatic 3rd nerve palsy and traumatic levator dehiscence. The most common acquired ptosis was aponeurotic followed by myogenic, neurogenic, traumatic and mechanical ptosis. Frontalis sling surgery is the most common surgery done for congenital ptosis. Use of polypropylene as a suspensory material gives a good functional outcome. Aponeurotic advancement surgery is the most common surgery performed for acquired ptosis.

STUDY ON MANAGEMENT OF PTOSIS BY DIFFERENT SURGICAL MODALITIES

BACKGROUND:Ptosis is derived from the greek word for falling and is the medical terminology describing a drooping or abnormal lowering of an anatomical area. Ptosis that obstruct the pupil may interfere with the normal development of vision, resulting in amblyopia in children2 .In adult it may impair the field of vision and interfere with activities of daily living Ptosis is broadly classified into congenital and acquired,based on age of onset of the ptosis.Ptosis that is present at birth or within the first year of life is called congenital ptosis. Ptosis that presents after the age of one year is termed acquired ptosis. The treatment of ptosis depends upon the underlaying etiology. Ptosis usually does not improve over time and nearly always require corrective surgery. Depending upon the severity of congenital ptosis ,patients should be monitored every 3-12 months for sign of amblyopia due to congenital ptosis. In mild cases of congenital ptosis observation is sufficient ,if no sign of amblyopia, strabismus and abnormal head posture are present. METHODS:This study was conducted in the Upgraded Department of Ophthalmology,LLRM Medical College,Meerut during 2018–2019. Study design-A Population based Prospective interventional study was done on patients selected from OPD and camps during 2018-2019. Plan & Work: All patients with ptosis who are attending ophthalmology OPD and admitted in eye wards were included in the study provided they fulfill the inclusion criteria. RESULTS AND CONCLUSION: The subjects in our study were more males 12(66.66%) than females(33.33%). In our study there were 12(66.66%) patients of myogenic ptosis,out of them 11(61.11%) had frontalis sling surgery and 1(5.55%) had levator resection surgery. There was 2(11.11%) cases of neurogenic ptosis which was congenital in nature and in which 1(5.55%) is operated with frontalis sling &1(5.55%) with levator resection surgery. Most commonly performed surgery was frontalis sling 14(77.77%) followed by levator resection 2(11.11%) and 2(11.11%).

Commentary: Retinal manifestations in patients following COVID-19 infection: A consecutive case series.

Coronavirus disease-2019 (COVID-19) pandemic has created a global health challenge owing to widespread mortality and morbidity. Alterations of the immune system, activation of coagulation pathways, and direct cytopathic effect of the virus are purported as the possible mechanisms that are responsible for the pathology of COVID-19. In addition to these, side effects of drugs and complications related to prolonged hospitalization and intensive care all combine to cause systemic manifestations of this virus, including ocular complications.[12] Multiple ophthalmic manifestations related to COVID-19 have been reported. Initially, when the pandemic started, ocular surface involvement was reported with self-limiting conjunctivitis being the earliest reported ocular manifestation.[3] Subsequently, a plethora of retinal manifestations have been reported in these patients, namely cotton wool spots, flame-shaped and dot-blot hemorrhages, retinal vascular occlusions, acute macular neuroretinopathy (AMN), paracentral acute middle maculopathy (PAMM), fungal retinitis, acute retinal necrosis, and serpiginous choroiditis. Neuro-ophthalmic manifestations like optic neuritis, papillo-phlebitis, extra-ocular muscle palsies, neurogenic ptosis, intracranial hypertension, cerebrovascular accident with vision loss, and orbital manifestations like mucormycosis and histiocytic orbital mass have also been reported in patients with COVID-19.[145] In the current study, authors have enumerated varied retinal manifestations following COVID-19. Patients with candida retinitis, tubercular choroidal abscess, and central serous chorioretinopathy (CSC) have been reported for the first time in this cohort.[6] Coagulopathy and endothelial dysfunctions are known associations of COVID-19 infection. In the eye, these manifest as cotton wool spots, central retinal vein occlusion, central retinal artery occlusion, AMN, and PAMM.[57] As reported in the current article, the aforementioned entities may occur during the active phase or even after recovery from COVID-19. Presence of cotton wool spots has been shown to be a potential biomarker in identifying underlying vascular and/or neurological comorbidity in COVID-19 patients.[7] Mean retinal artery diameter and the mean retinal vein diameter (MVD), measured using the Automated Retinal Image analyzer, have been shown to be higher in COVID-19 patients compared to healthy cohorts. MVD was negatively correlated with the time from onset of symptoms and positively correlated with disease severity.[8] Herein lies the role of an ophthalmologist and ocular examination in COVID-19 patients. Fundus examination is a simple, easy to perform and non-invasive. It has been shown to predict systemic endothelial dysfunction and triggering of the inflammatory cascade in subclinical and asymptomatic patients, thereby allowing earlier institution of appropriate therapy and potentially improving long-term morbidity and mortality.

English

BACKGROUND Blepharoptosis is a relatively common form of eyelid malposition in both children and adults. Along with being a cosmetic blemish, ptosis is associated with high incidence of amblyopia, especially in young children with severe ptosis. This can have a negative impact on psychosocial development of a child. Hence, it becomes necessary for a general physician as well as for a general ophthalmologist sitting at a primary health care centre, to know the clinical profile of such patients. We wanted to study the demography, clinical presentation and management of blepharoptosis patients seen in our institute over a period of 2 years. METHODS 45 patients with ptosis who reported at our tertiary care hospital in North India from January 2017 to December 2018, were included in the study. Demographic data, clinico-etiological profile, management of ptosis including outcome of surgeries performed was analysed retrospectively. Data was presented as frequencies and mean ± standard deviation (SD). RESULTS The study comprised of a total of 45 patients. The mean age of presentation was 17.4 years. Maximum number of patients i.e. 17 (37.7 %) were from the age group 11 - 20 years. Male to female ratio was 2.75 : 1. Congenital ptosis was found to be the most common type seen in 36 (80 %) patients. Simple congenital ptosis (34 patients) being the commonest among congenital type. 4 (17.7 %) patients had aponeurotic ptosis. 3 (6.6 %) patients had neurogenic ptosis. Myogenic ptosis was seen in 2 (4.4 %) patients. Majority of our cases had severe degree of ptosis (57.7 %) and poor LPS action (46.6 %). LPS resection was done in 21 (46.6 %) patients, LPS reinsertion in 1 (2.2 %), sling surgery in 18 (40 %) and Fasanella Servat operation in 1 (2.2 %) patient. 2 (4.4 %) patients were medically managed and 2 (4.4 %) were kept under observation. The outcome of surgery was good in 28 (62.2 %) patients, fair in 7 (15.5 %) and poor in 6 (13.3 %) patients. Presence of amblyopia was noted in 21 patients i.e. 46.7 % of the total patients. Marcus Gunn Jaw winking phenomenon was elicited in 2 (4.4 %) patients. Bell’s phenomenon was found in 4 (8.8 %) patients. 5 (11.1 %) patients had exotropia, 3 (6.6 %) had hypotropia and 1 (2.2 %) patient had complete ophthalmoplegia. CONCLUSIONS The study highlights the demographics, clinical profile and management of congenital blepharoptosis patients seen at a centre of excellence in North India. The study is helpful for ophthalmologists in guiding diagnosis, evaluation and management of such patients and hence, long-term successful outcome of this disease. KEYWORDS Blepharoptosis, Levator Resection, Frontalis Sling Surgery

The Epidemiology and Clinical Features of Blepharoptosis in Taiwanese Population.

Blepharoptosis describes a condition of low-lying upper eyelid that may affect individuals of all ages under various etiologies. It may be of congenital or acquired form by the timing of onset or be divided into myogenic, neurogenic, aponeurotic, or mechanical types according to the mechanism. Our goal was to report the characteristics of age-specific blepharoptosis and to analyze the association between levator function (LF) and ptosis severity of each ptosis subtype. The retrospective, single-center, cross-sectional study consisted of patients diagnosed with blepharoptosis in the plastic surgery practice at a medical center between September 2009 and May 2017. We reported patients' age at presentation, sex, laterality of ptosis, etiology, classification, and evaluation of ptosis including levator function and ptosis severity. During a nine-year span of study, a total of 1975 eyelids of 1164 Taiwanese patients aged between 2 and 88years were enrolled in the research (mean = 57.73 ± 13.41years). The female-to-male ratio was 2.72 (95% confidence interval [CI]: p < 0.0001). Acquired blepharoptosis and bilateral blepharoptosis were more frequently observed (55.85%, p < 0.0001 and 69.67%, p < 0.0001, respectively). In age-specific relative incidence of blepharoptosis, myogenic ptosis was the majority in patients younger than 40years. Early onset of aponeurotic ptosis was observed in young contact lenses wearers. Aponeurotic blepharoptosis was the predominant type of ptosis in the senior population older than 40years (p < 0.0001). Among the subtypes, mechanical ptosis had the most preserved LF (p < 0.0001). LF and MRD1 had statistically positive correlations in all subtypes of blepharoptosis, in which neurogenic ptosis demonstrated the severest levator dysfunction for each millimeter in MRD1 reduction. Of the 1164 Taiwanese patients, blepharoptosis had a higher propensity for female gender and the age between the second to fourth decades. Bilateral involvement of blepharoptosis with acquired type was frequently diagnosed. Myogenic ptosis had a preponderance in age younger than 40years, while aponeurotic ptosis usually affects senile population. Many mild degree myogenic ptosis was simultaneously recognized in young-aged adults seeking aesthetic double eyelid surgery. Early onset of acquired aponeurotic ptosis was also observed in contact lens wearers given the trend of decorative contact lens use. Levator dysfunction was implicated in the pathology of not only myogenic ptosis but aponeurotic, mechanical, and neurogenic ptosis. Moreover, levator function of neurogenic ptosis was most severely impacted in each MRD1 reduction among all subtypes of blepharoptosis. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Tarsal switch using an anterior approach to correct severe ptosis.

BackgroundTo present the outcomes of the tarsal switch procedure using an anterior approach to correct severe ptosis with poor levator muscle function (<4 mm) with absent or poor Bell’s phenomenon.MethodsThis retrospective case series included 11 patients with severe neurogenic or acquired myogenic palpebral ptosis. All patients underwent the tarsal switch procedure through an anterior approach from 2012 to 2015. Margin reflex distance (MRD1 and MRD2) and the palpebral fissure were evaluated preoperatively and postoperatively. Data were compared using the Wilcoxon signed-rank test. P-values <0.05 were considered to indicate statistical significance.ResultsSurgery was performed on 18 eyelids (11 patients). The median age at surgery was 57 years (range, 29-86 years). Four patients had unilateral ptosis and seven had bilateral ptosis. Nine patients had myogenic ptosis and two had neurogenic ptosis. Postoperatively, the chin-up position improved in all patients. The MRD1 increased statistically significantly, from 0 mm preoperatively to 1.0 mm postoperatively (P=0.001). The MRD2 decreased statistically significantly, from 4.5 mm preoperatively to 3.0 mm postoperatively (P=0.001). The palpebral fissure did not change (4.0 mm preoperatively to 4.0 mm postoperatively) (P=0.13).ConclusionsThe tarsal switch procedure through an anterior approach is an effective alternative for correcting severe ptosis, especially neurogenic or acquired myogenic ptosis. This procedure can be performed with minimal risk of ocular surface exposure and provides stable outcomes.

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.

A Case of Complete Recovery of Isolated Neurogenic Ptosis after Trauma

Purpose: To report a rare case of isolated neurogenic blepharoptosis secondary to eyelid trauma. Case summary: A previously healthy 41-year-old male was evaluated for decreased visual acuity and blepharoptosis in the left eye after ocular trauma. On ophthalmologic examination, visual acuity in the left eye was hand motion, intraocular pressure was 29 mm Hg, hematoma and eyelid edema were minimal. The patient had complete unilateral ptosis with superficial upper eyelid laceration. Additional findings in the left eye included fracture of the medial orbital wall, hyphema, iris sphincter muscle tear, iridodialysis and conjunctival laceration. The other examinations were unremarkable with full ocular motility. Because of iris sphincter muscle tear and iridodialysis, the pupillary reaction could not be evaluated. His left upper eyelid drooped completely and levator function test (LFT) was 0 mm. He was diagnosed with an isolated neurogenic blepharoptosis and received oral prednisolone at a dose of 1 mg/kg per day for 7 days with gradual tapering. One month later, the patient had normal symmetric lid height and completely restored levator function. J Korean Ophthalmol Soc 2014;55(8):1261-1265

Management of Severe Bilateral Ptosis in a Patient With Midbrain Infarction: A Case Report

Ptosis could be caused by oculomotor nerve palsy in the midbrain infarction. Bilateral ptosis has been reported in several reports, which focused on clinical characteristics of midbrain infarction. Little research attention has been paid to the treatment of patients with bilateral ptosis in midbrain infarction. We experienced a case of severe bilateral ptosis occurring after midbrain infarction. The patient could not open her eyes, perform basic activities or achieve effective rehabilitation. Neurogenic ptosis can improved after the underlying cause is treated. However, in this case, bilateral ptosis was not improved after conservative care for 6 months and the patient remained limited in activities of daily living and mobility. Surgical correction of bilateral ptosis was done by the resection of both Muller's muscles. After surgical correction, the bilateral ptosis was much improved and the effect persisted for at least 6 months.

Exposure keratopathy following silicone frontalis suspension in adult neuro‐ and myogenic ptosis

To evaluate the incidence of exposure keratopathy following silicone frontalis suspension in adult neuro- and myogenic blepharoptosis. Retrospective noncomparative analysis of the charts of 69 cases (101 eyelids) of silicone frontalis suspension. Sixty-one patients (93 eyelids) had myogenic ptosis, and eight patients (eight eyelids) had neurogenic ptosis. Preoperative diagnoses included chronic progressive external ophthalmoplegia, myotonic dystrophy, oculopharyngeal dystrophy, third cranial nerve palsy because of trauma or other causes. Average age at the time of operation was 54. Mean interval between the intervention and the first and second postoperative control was 8 and 28 months, respectively. Thirty-one patients (31 eyelids) needed a second follow-up visit. Postoperative punctate epithelial erosions (PEE) were encountered most frequently in patients with Steinert's disease (42% of eyes) and congenital ptosis (33% of eyes). Patients with oculopharyngeal dystrophy did not develop PEE. Corneal ulceration developed in three eyes (two patients): one eye was successfully treated with local antibiotic ointments and lubricants, a bilateral corneal ulceration in the second patient was successfully treated with partial conjunctival grafts. This study cohort demonstrated a 26% risk of exposure keratopathy following silicone frontalis suspension. The risk of major corneal complications, such as ulceration, was low (3%).

Upper Eyelid Ptosis Surgery Using a Preparatory Ocular Prosthesis

When an ocular prosthesis is unable to correct upper eyelid ptosis, surgery is performed with the existing prosthesis, which may be difficult and unsatisfactory. We used an alternative approach, in which the prosthesis was modified as a preparation to surgery. This retrospective, noncomparative, interventional case series included 26 anophthalmic and 3 microphthalmic patients with unilateral, moderate to severe upper eyelid ptosis who underwent levator aponeurosis surgery via an anterior approach. Excluded were cases of congenital anophthalmos, contracted socket, and neurogenic ptosis. Before surgery, the prosthesis was modified to vertically align the pupils while neglecting the position of the upper eyelid. The outcome measures were palpebral fissure height and cosmetic appearance. The amount of ptosis before the procedure ranged from 1 to 6 mm (mean, 3 mm). After surgery, 24% (7 of 29) of patients received a minor adjustment to the preparatory prosthesis to improve the pupil or eyelid position. After the entire procedure, the ptosis was symmetrically corrected with the contralateral eye in 19 patients (66%), with 1 mm of residual ptosis in 6 patients (17%), and with 2 mm of residual ptosis in 4 patients (14%). No overcorrection was seen. The alternative sequence of a preparatory prosthesis before surgery provides good results in the correction of moderate to severe ptosis.

Ptosis in patients with hemispheric strokes. Averbuch-Heller L. Leigh RJ. Mermelstein V. Zagalsky L. Streifler JY. Neurology 2002;58:620–624

Ptosis caused by lesions of the cerebral hemispheres without involvement of the third cranial nerves or oculosympathetic pathways is considered rare. So-called cerebral ptosis has been most often reported with unilateral, usually right hemispheric lesions. However, the frequency of cerebral ptosis in patients with strokes has not received systematic study. The purpose of this study was to determine the frequency of ptosis in patients with acute hemispheric stroke and to identify stroke features associated with ptosis. Eyelid function was studied in 64 consecutive patients with acute hemispheric stroke and 40 age-matched subjects with no known neurologic disease. All underwent comprehensive neuroophthalmologic and general neurologic examination within 48 hours of admission, including measurement of palpebral fissures, marginal reflex distance, and range of upper lid movement. Only patients who could cooperate with eyelid testing were included Brain CT scans were obtained for all patients. Neurogenic ptosis was found in 24 patients (37.5%) with stroke, which was bilateral in 10 patients and unilateral in 14. None of the control subjects had neurogenic ptosis. All patients with stroke with ptosis had a hemiparesis, most often contralateral to the side of the ptosis in those patients with unilateral or highly asymmetric ptosis. CT evidence of right-sided hemispheric cortical infarction was more common in patients with strokes with ptosis. Rightward gaze deviation and upgaze paresis were more common (P < .05) in the patients with ptosis compared with others who had had strokes. In five patients with large hemispheric infarction, complete bilateral or asymmetric ptosis was the first sign of imminent herniation, preceding pupillary dilatation and ocular motor deficits. The authors conclude that ptosis occurs frequently in patients with hemispheric strokes, especially in association with right hemispheric lesions. Complete bilateral ptosis is usually caused by large infarctions and may be a premonitory sign of an impending herniation.—Nancy J. Newman

Ptosis in patients with hemispheric strokes

Cerebral ptosis is considered rare; it has been reported with unilateral, usually right hemispheric lesions. However, the frequency of cerebral ptosis in patients with strokes has not received systematic study. To determine the frequency of ptosis in patients with acute hemispheric stroke and to identify stroke features associated with ptosis. Eyelid function was studied in 64 consecutive patients with acute hemispheric stroke and 40 age-matched subjects with no known neurologic disease. All underwent comprehensive neuro-ophthalmologic and general neurologic examination within 48 hours of admission, including measurement of palpebral fissures, marginal reflex distance, and range of upper lid movement. Only patients who could cooperate with eyelid testing were included. Brain CT scans were obtained for all patients who had had strokes. Twenty-four (37.5%) of the patients with strokes had neurogenic ptosis, which was bilateral in 10 and unilateral in 14. None of the control subjects had neurogenic ptosis. All patients with strokes with ptosis had a hemiparesis. Rightward gaze deviation and upgaze paresis were more common (p < 0.05) in the patients with ptosis compared with others who had had strokes. CT evidence of right-sided hemispheric cortical infarction was more common in patients with strokes with ptosis (p < 0.05). In five patients with large hemispheric infarction, complete bilateral or asymmetric ptosis was the first sign of imminent herniation, preceding pupillary dilation and ocular motor deficits. Ptosis occurs frequently in patients with hemispheric strokes, especially in association with right hemispheric lesions. Complete bilateral ptosis is usually caused by large infarctions and may be a premonitory sign of an impending herniation.