Normal Eyelid Position Research Articles

Computer technologies in diagnostics and treatment of worsening post-enucleation socket syndrome

To demonstrate the capabilities of modern computer technologies in diagnostics and treatment of patients with worsening post-enucleation enophthalmos. The retrospective study included 6 patients (4 male and 2 female) aged 29-68 years who exhibited signs of PESS in 2017-2018. To define the orbital condition, patients underwent multispiral computed tomography (MSCT) and magnetic resonance imaging (MRI) followed by image analysis with computed exophthalmometry and step-by-step computed exophthalmometry. Results of these examinations helped construct 3D-models of patients' orbits, which were then used to calculate the parameters of the silicone implants. Patient-specific silicone implants were implanted into their orbits during surgery under general anesthesia. Implantation of the patient-specific silicone implant resulted in increase of the volume behind orbital prosthesis and correction of post-enucleation enophthalmos in all patients allowing them to use thinner, more mobile ocular prosthesis, and restore normal eyelid position. The patients also noted better appearance of the eye and personal comfort. Modern visualization methods along with computer analysis and modelling, as well as technologies to produce medical products enable creation of the best suitable patient-specific orbital implants. This allows achieving better clinical results and better quality of life for patients with monolateral anophthalmos.

A comparison of the lateral tarsal strip with everting sutures and the Quickert procedure for involutional entropion.

To provide evidence of statistically significant difference in the surgical outcome of the lateral tarsal strip with everting sutures (LTS+ES) versus the Quickert procedure (QP) in the treatment of involutional entropion. In a prospective randomized comparative trial, 66 eyelids of 52 patients with primary involutional lower eyelid entropion were recruited. Thirty-six eyelids were randomized to QP, and 30 eyelids were randomized to LTS+ES. Surgery was performed by a single surgeon. Postoperative follow-up was scheduled after 2weeks, 8 and 14months. Successful surgery was defined as a normal eyelid position at rest and inability to induce entropion on forced eyelid closure at or before the 14-month follow-up visit. A total of 66 eyelids of 52 patients were enrolled in the study. Three patients did not complete follow-up (1 did not attend the 8months follow-up visit; 2 did not attend 14months follow-up visit). Of the 63 patients, a single eyelid [success probability 0.97; confidence interval (CI) 0.92-1] in the QP group and two treated eyelids [success probability of 0.93; CI: 0.85-1] in the LTS+ES group had a recurrence of a lower eyelid entropion after 14months. There was no statistically significant difference in surgical failure between the LTS+ES versus QP (Log-rank test: p=0.46). These data provide strong evidence that success rates at 14months are similar in patients treated with either techniques (LTS+ES versus QP).

Posterior layer advancement of lower eyelid retractors with transcanthal canthopexy for involutional lower eyelid entropion.

PurposeThe purpose of this study was to examine the surgical outcome of posterior layer advancement of the lower eyelid retractors (LER) with transcanthal canthopexy for involutional lower eyelid entropion.Patients and methodsFifty-one eyelids of 41 patients with involutional entropion and vertical and horizontal laxities that underwent posterior layer advancement of the LER with transcanthal canthopexy were retrospectively reviewed. As a control, we also reviewed previously reported data from 47 entropic eyelids of 37 patients with vertical and horizontal laxities that were successfully corrected using LER advancement and a lateral tarsal strip procedure. Surgical success was defined as the normal eyelid position without contact of any cilia to the globe at the last follow-up examination.ResultsAll eyelids in the present study group were judged as successfully treated without recurrence after 13.9±9.2 months of follow up (mean±SD). The surgical time in the present study group (22.4±5.5 min) was significantly shorter than that in the control group (mean 31.3±4.9 min; P<0.001; Student's t-test). None of the patients showed lateral canthal deformity after surgery.ConclusionsPosterior layer advancement of the LER with transcanthal canthopexy provided complete surgical success with shorter surgical time without the risk of lateral canthal deformity. Posterior layer advancement of the LER with transcanthal canthopexy can be an option for correction of involutional lower eyelid entropion in patients with both vertical and horizontal laxities.

The Impact of Hering's Law in Blepharoptosis: Literature Review.

The aim of this literature review is to examine Hering's law, a well-documented phenomenon in blepharoptosis patients, with 10% to 20% noted in cases of unilateral ptosis. Predominantly presenting as contralateral eyelid drop postoperatively, it poses a challenge for eyelid surgeons in the pursuit of symmetry and appropriate eyelid height. Proper preoperative evaluation is of utmost importance, consisting of one of either lifting test, covering test, or phenylephrine test. A deeper understanding of Hering's law further provides adequate information for optimal management of ptosis. In regard to ptosis etiology, congenital ptosis does not appear to have a distinct relation to positive Hering's law, commonly associated with a low incidence, when compared with acquired ptosis. Ptosis in the dominant eye seems to be related to a higher incidence of the phenomenon than ptosis in the nondominant eye, with statistical significance in studies ranging from P < 0.001 to P = 0.09. This can be explained as an innate response for increased innervation to regain the field of vision. Both ptosis severity and levator function appear to be of lesser importance than ptosis etiology, with minimal incidence of Hering's law in congenital ptosis regardless of these factors. It is, however, noted that ptosis severity has direct association with contralateral eyelid position in acquired ptosis, whereas there is a lack of studies for levator function. In the event of preoperative contralateral eyelid drop, surgeons should consider simultaneous surgery instead of delayed surgery for bilateral ptosis (P = 0.002). For unilateral ptosis, although reoperation is done per patient request, it may be more appropriate to first wait for roughly 2 weeks and reassess for self-regulation to a normal eyelid position.

Effect of Suturing the Silicone Rod to the Tarsal Plate and the Suture Material Used on Success of Frontalis Suspension Surgery

To evaluate the effect of suturing the silicone rod to the tarsal plate and the suture material used in suturing on surgical success of frontalis suspension for congenital ptosis. Eighty eyes of 56 consecutive patients who underwent frontalis suspension surgery using silicone rods for congenital ptosis between 2005 and 2011 were included in this retrospective study. The surgical results of eyes were compared, in which silicone had not been sutured to the tarsal plate (group 1), with those sutured with monofilament polypropylene suture (group 2), and those sutured with polybutylate-coated braided polyester suture (group 3). Surgical success indicated that the postoperative eyelid position was maintained within 1 mm of the normal eyelid position, that is, 1 mm below the superior limbus in bilateral cases and the same level with the other eyelid in unilateral cases, in the primary position of gaze. Postoperative eyelid level beyond these limits was defined as surgical failure. The mean follow up was 16.3 months (6-38 months) and the mean age was 5.48 years (1-24 years). Thirty were male and 26 were female patients. Surgical failure occurred in 9 of 18 (50%) cases in group 1, in 5 of 24 (20.8%) cases in group 2, and in 5 of 38 (13%) cases in group 3 during the follow-up period after adequate eyelid elevation had been achieved just after the operation. The difference between surgical success rates in group 1 and group 2 (p = 0.047) and group 1 and group 3 (p = 0.003) was statistically significant. However, the difference between group 2 and group 3 did not reach statistical significance. Suturing the silicone rod to the tarsal plate increases the surgical success rates of frontalis suspension surgery for congenital ptosis. Suturing with polybutylate-coated braided polyester, even though statistically insignificant, seems to be more effective than suturing with monofilament polypropylene.

Outcomes of Mild to Moderate Upper Eyelid Ptosis Correction Using Müllerʼs Muscle–Conjunctival Resection

Müller's muscle-conjunctival resection is used to correct mild to moderate ptosis commonly encountered in the rejuvenation patient population. The authors examined its efficacy and analyzed variables that potentially affect outcomes. Patients who underwent ptosis correction using Müller's muscle-conjunctival resection with greater than 10-month follow-up were included. Amount of ptosis reduction, eyelid symmetry, effects of concomitant facial aesthetic operations, and adverse outcomes were analyzed. Patients were grouped into medium- (<24 months after surgery) and long-term follow-up (>24 months) cohorts to determine whether outcomes changed over time. Forty patients with a mean follow-up of 28 months combined for a total of 70 resection operations. Resection significantly reduced ptosis by a mean of 1.48 ± 0.88 mm (p < 0.001), corresponding to 0.19 mm of eyelid elevation for every 1.0 mm of Müller's muscle resected. The procedure successfully corrected 84 percent of eyelids to within 0.5 mm and 94 percent to within 1.0 mm of normal eyelid position. On patients with asymmetric ptosis, it significantly improved eyelid symmetry to within 1.0 mm from 85 percent of patients before surgery to 95 percent after surgery, and to within 0.5 mm from 53 percent before surgery to 75 percent of patients after surgery (p = 0.036). Furthermore, the mean correction of ptosis was not significantly different between medium- (1.58 ± 0.93 mm) and long-term (1.32 ± 0.93 mm) follow-up patients (p = 0.258). Müller's muscle-conjunctival resection is an effective long-term solution to mild to moderate eyelid ptosis and asymmetry, and can be effectively performed concomitantly with other aesthetic facial procedures. Therapeutic, IV.

Subcaruncular Approach for Medial Eyelid Repair: A Simplified Technique

Introduction:Laxity of the medial canthal tendon (MCT) is commonly encountered in clinical practice. The techniques described in the literature to correct MCT laxity often involve extensive dissection, with potential risk to the lacrimal system. We describe a simple and minimally invasive MCT repair in which the medial eyelid is secured to the anterior central portion of the MCT via a subcaruncular approach without disturbing the normal eyelid position or the lacrimal system.Materials and Methods:A retrospective analysis of 30 patients undergoing MCT repair in all 4 eyelids was performed. Eyelids with moderate to severe MCL laxity were treated by this technique.Results:Patient age ranged between 55 and 90 years, with a mean of 74.2 years. Upper lid distraction ranged from 8–20 mm (mean 13 mm). Lower lid distraction ranged from 14–30 mm (mean 23.4 mm). In 87% of patients, eyelid laxity diminished postoperatively, and 13% had incomplete correction of the laxity with recurrence of symptoms. Recurrence was attributed to sutures pulling through attenuated lax lids and to mechanical eyelid stretching caused by sleeping on the face and/or rubbing the eyes. After reoperation in 3 patients, the lids regained normal position and tone, and symptomatic improvement was noted. No patients had postoperative complications involving the lacrimal system with this approach.Conclusions:The described MCT repair technique is an anatomically simple approach for eyelids with moderate to severe MCT laxity; it may be useful for surgeons who otherwise would defer complex repair of the MCT.

Subcaruncular Approach for Medial Eyelid Repair: A Simplified Technique

Introduction: Laxity of the medial canthal tendon (MCT) is commonly encountered in clinical practice. The techniques described in the literature to correct MCT laxity often involve extensive dissection, with potential risk to the lacrimal system. We describe a simple and minimally invasive MCT repair in which the medial eyelid is secured to the anterior central portion of the MCT via a subcaruncular approach without disturbing the normal eyelid position or the lacrimal system. Materials and Methods: A retrospective analysis of 30 patients undergoing MCT repair in all 4 eyelids was performed. Eyelids with moderate to severe MCL laxity were treated by this technique. Results: Patient age ranged between 55 and 90 years, with a mean of 74.2 years. Upper lid distraction ranged from 8–20 mm (mean 13 mm). Lower lid distraction ranged from 14–30 mm (mean 23.4 mm). In 87% of patients, eyelid laxity diminished postoperatively, and 13% had incomplete correction of the laxity with recurrence of symptoms. Recurrence w...

Lacrimal Caruncle: Continuation to the Lower Eyelid Retractors

To examine the relationship between the lacrimal caruncle and the lower eyelid retractors and to study the shape and position of the lacrimal caruncle in relation to the lower eyelid margin. A transcaruncular approach was used to investigate the direction of the lacrimal caruncle shift in 14 medial orbital decompressions (7 patients) and 10 medial orbital wall fracture reductions (10 patients). Eighty lacrimal caruncles in 40 normal volunteers were examined regarding the position of this structure in relation to the lower eyelid retractors and its shape in connection to the lower eyelid margin. Direct investigation of whether the lower eyelid retractors continued to the lacrimal caruncle was performed during 4 lazy-T procedures (2 patients). All the severed lacrimal caruncles moved inferolaterally. The volunteers' lacrimal caruncles were situated adjacent to the lower eyelid retractors, had an ovoid shape, and were positioned obliquely with an inferolateral direction. In the normal eyelid position, the superior border of the lacrimal caruncle was aligned with the lower eyelid margin. During the lazy-T procedures, the lower eyelid retractors were shown to have direct connection to the lacrimal caruncle. The lacrimal caruncle has a direct connection to the lower eyelid retractors that plays an antagonistic role to the medial rectus caspulopalpebral fascia in the movement of the lacrimal caruncle, and it is positioned obliquely, directing inferolaterally with its superior border in level with the lower eyelid margin.

A Randomized Controlled Trial Comparing Everting Sutures with Everting Sutures and a Lateral Tarsal Strip for Involutional Entropion

To determine whether there is a statistically significant difference in the surgical outcome of everting sutures (ES) alone versus everting sutures with a lateral tarsal strip (ES+LTS) in the treatment of involutional entropion. Prospective randomized comparative trial. Sixty-three patients with primary involutional lower eyelid entropion were enrolled in the study. The age range was 54 to 94 years, with a mean age of 77 years. Baseline characteristics of the comparative groups were similar. Patients requiring primary surgical repair for involutional entropion were selected, and those providing informed consent were randomized for surgery. Thirty-six patients were randomized to ES alone, and 27 patients were randomized to ES+LTS. Patients were evaluated at 3 weeks and 6, 12, and 18 months postoperatively. Successful surgery was defined as a normal eyelid position at rest and inability to induce entropion on tetracaine provocation testing at or before the 18-month follow-up visit. Eight patients were lost to follow-up (7 had ES alone). Of the 55 patients with complete follow-up data, there were 6 failed procedures in the patients who underwent ES alone and no failed procedures in the patients who underwent ES+LTS (P = 0.02). These data provide strong evidence that success rates at 18 months are higher in patients treated with ES+LTS procedure compared with ES alone.

Nodular Fasciitis Presenting as a Large Mass in the Upper Eyelid

A 3-year-old boy was examined for a large nodular fasciitis in the upper eyelid. The lesion was confined to the preseptal plane of the upper eyelid, provoking mechanical ptosis. Excision by an eyelid crease approach was sufficient to restore normal eyelid position.

Simple Effective Surgery for Involutional Entropion Suitable for the General Ophthalmologist

To compare the long-term success, recurrence, and complication rate of involutional entropion surgery using the lateral tarsal strip and everting sutures when performed by surgeons in training (resident or fellow) and specialist oculoplastic surgeons (attending supervising physician). Prospective, interventional, comparative, clinical case series. Adult patients with involutional entropion. Lateral tarsal strip and everting sutures (LTS+ES) by residents, fellows, or attending supervising physician. A minimum of 12 months of postoperative follow-up was required. Patients' symptoms and clinical examination to confirm a normal eyelid position (no entropion or secondary ectropion) at rest and with forced orbicularis contraction with the topical amethocaine (tetracaine) test. This test is described. Fifty-five consecutive patients, aged 57 to 91 years (mean, 77 years) underwent LTS+ES surgery on 62 eyelids. Surgery was performed by a consultant ophthalmic oculoplastic surgeon (attending supervising physician) in 8 eyelids and by 20 different trainees, residents, and fellows in 54 eyelids. Six patients died (11%) within 6 months of surgery and 2 patients (3.5%) were lost to follow-up, resulting in 47 evaluable patients (54 eyelids). The follow-up period was 12 to 34 months (mean, 18 months). Fifty-three of 54 eyelids (98%) had a successful outcome with no recurrence. The surgery was effective when performed by different grades of surgeon (P>0.4). The LTS+ES is a simple operation for the correction of involutional entropion that can be performed effectively by both residents and fellows.

Mesencephalic Clefts and Eye Movement Disorders

We read with interest the article by Lagreze et al 1 that was published in the April 1996 issue of theArchives. The authors described 2 patients with similar eye movement disorders that they attributed to a midline mesencephalic cleft. This clinicalradiographic association had not been previously reported. We would like to share a similar case. A 67-year-old man had a history of ptosis and diplopia since early adulthood. Photographs from childhood confirmed normal eyelid position and ocular alignment until the age of 18 years. His diplopia required increasing prism diopter (Δ) strength during a 20-year period, but he preferred to use a compensatory head turn. No family members had similar problems. In the past 10 years, a slowly progressive gait ataxia had developed. On neuro-ophthalmic examination, his visual acuity was 20/20 OU and the visual fields were normal. The pupils, anterior segments, and fundi were normal. An external examination

Early Correction of Severe Congenital Ptosis

Twelve infants with severe unilateral or bilateral congenital ptosis were surgically repaired before 1 year of age in an attempt to achieve early functional and cosmetic improvement. In all cases, a frontalis suspension using polyfilament nylon suture (Supramid Extra) was performed. Postoperatively, 10 patients achieved near normal eyelid position and all had resolution of their chin-up head posture. Two slings eventually failed, requiring repeat procedures for recurrent ptosis. Two developed signs of cellulitis that were successfully treated with oral antibiotics.

Anterior levator resection in congenital genuine blepharoptosis. A follow-up of 55 operated eyelids.

Fifty-five eyelids operated on for congenital blepharoptosis over a 10-year period were followed up, with a mean observation time of seven years. Ptosis was on the right side in 12 patients, the left side in 20, and bilateral in 12. Ptosis was regarded as being slight in 32 eyelids, moderate in 10 and severe in 14. The operative procedure was resection of the levator muscle and its aponeurosis through an anterior approach. Fifty-five percent of the patients with slight ptosis were improved, with the eyelid having a normal position. All the patients with moderate ptosis were improved--half to a normal eyelid position, and half with a residual slight ptosis. All but one patient with severe ptosis were improved, and half of these to a normal eyelid position. It is concluded that this operation can be used for all types of congenital ptosis, and especially in severe cases, where it produces better results than e.g. the frontalis sling procedure.