Preoperative Levator Function Research Articles

Lower eyelid position before and after blepharoptosis repair

ABSTRACT Purpose This study aimed to examine the changes in lower eyelid position after blepharoptosis surgery and the factors that influence the outcome. Methods We conducted a retrospective study of 155 eyes of 89 patients who underwent blepharoptosis surgery between June 2019 and October 2022. The margin reflex distance (MRD)-1 and MRD-2 were examined preoperatively and 3 months postoperatively in two groups: one with lower scleral show (LSS) (n = 37) and one without LSS (n = 118). The clinical characteristics of the two groups were compared. Results Both the LSS and non-LSS groups showed significant postoperative improvement in MRD-1 scores (p < .01, p < .01, respectively). MRD-2 was significantly reduced in the LSS group, while it remained unchanged in the non-LSS group (p < .01, p = .27, respectively). There were no significant differences between the two groups in age, sex, history of hard contact lens use, preoperative levator function, use of topical steroids, history of endophthalmic surgery, or history of filtration surgery; however, the LSS group significantly used prostaglandin analogs (PGAs) (p = .03). Postoperatively, MRD-2 decreased in 13 eyes (35.1%) and was maintained in 24 eyes (64.9%) in the LSS group and was maintained in all eyes in the non-LSS group. In the LSS group, we also examined the association between postoperative MRD-2 reduction and the use of PGAs and found that more patients with MRD-2 reduction used PGAs (p = .02). Conclusion Lower scleral show in PGAs-associated blepharoptosis is expected to improve after blepharoptosis surgery.

A novel technique for small-incision levator resection with a double mattress suture for ptosis correction.

To introduce a novel technique for small-incision levator resection in ptosis surgery and evaluate its efficacy in a pilot study among patients affected by congenital or aponeurotic ptosis. We prospectively enrolled congenital and aponeurotic ptosis patients if their levator function was not poor (≥5 mm) from June 2021 through October 2022. Surgical technique involved a 1-cm lid crease incision, minimal dissection, and creating a loop passing through the tarsus and levator aponeurosis. Success was defined as postoperative MRD-1 ≥3 mm and inter-eyelid MRD-1 difference ≤1 mm. Eyelid contour quality was scored excellent, good, fair, and poor according to its curvature and symmetry. Sixty-seven eyes (35 congenital and 32 aponeurotic) were included in the study. Mean age was 34±19 years (range, 5-79 years). Mean preoperative levator function and levator resection amount were 9.53 mm and 8.39 mm in the congenital group and 12.34 mm and 4.15 mm in the aponeurotic group, respectively. Mean pre- and postoperative MRD-1 was 1.61 mm and 3.27 mm respectively (P<0.001). The overall success rate was 82.1% (95% C.I: 71.7-89.8%); the result was failure in 12 cases, of which 11 had under-correction. Preoperative MRD-1 was correlated with a success rate (P=0.017). The described technique shows non-inferior results to the previously described surgical methods and also it shows very good lid contour outcome and minimal lag. The findings suggest that the double mattress single suture technique can be used in both congenital and aponeurotic ptosis.

Levator muscle resection for simple congenital ptosis: its impact on preoperative levator function and dose-response ratio

ObjectifLa présente étude avait pour principal objectif de calculer la relation dose-réponse chez des patients présentant différents degrés de fonction musculaire du releveur à la suite d'une résection de ce muscle dans le traitement d'un ptosis congénital simple. Le paramètre secondaire consistait en une évaluation du taux de réussite et de l'effet de la résection du releveur sur sa fonction après l'intervention. MéthodesDans le cadre de cette étude rétrospective, les dossiers médicaux de patients ont été passés en revue en fonction de l’âge, du sexe, de la latéralité, des mesures pré- et postopératoires (hauteur de la fente palpébrale, distance entre le centre de la pupille et le bord supérieur du tarse [MRD1, pour marginal reflex distance 1] et fonction musculaire du releveur), de l'ampleur de la résection du releveur, de la durée du suivi et des complications postopératoires. RésultatsSur l'ensemble des 154 patients (âge moyen : 17,12 ± 11,14 ans), 54 patients bénéficiaient d'une excellente fonction musculaire du releveur, 41, d'une bonne fonction et 59, d'une fonction acceptable. Après l'intervention, la fonction musculaire moyenne du releveur est passée de 8,81 ± 3,40 mm à 11,29 ± 3,25 mm. L'ampleur de l'amélioration dans les 3 groupes se chiffrait comme suit : 3,18 ± 2,63 dans le groupe fonction excellente, 2,53 ± 2,24 dans le groupe bonne fonction et 1,92 ± 1,80 mm dans le groupe fonction acceptable, respectivement. Le taux de réussite s’élevait à 81,8 %, sans qu'il n'y ait de différence statistiquement significative entre les 3 groupes. Selon la régression logistique multivariée, un âge plus avancé, une anesthésie locale et un ptosis moins important étaient tous des facteurs de prédiction d'une réussite de l'intervention. On a réalisé un tableau de la relation dose-réponse qui permet de calculer le degré de résection du releveur pour obtenir 1 mm de MRD1 et une amélioration de la fonction musculaire du releveur. ConclusionsLe taux de réussite de la résection du releveur en présence d'un ptosis congénital simple est élevé. La fonction musculaire du releveur s'est améliorée de manière significative après l'intervention, et le taux d'amélioration était plus élevé chez les patients qui bénéficiaient déjà d'une meilleure fonction du releveur avant la chirurgie.

Maximal Levator Resection Beyond Whitnall's Ligament in Severe Simple Congenital Ptosis with Poor Levator Function.

PurposeTo evaluate the functional and cosmetic outcomes, as well as factors that influence surgical success of maximal levator resection beyond Whitnall’s ligament in patients with poor levator function (LF) and severe simple congenital ptosis.MethodsThis retrospective interventional study included patients with severe simple congenital ptosis and LF of ≤4 mm who had undergone maximal levator resection beyond Whitnall’s ligament with a minimum of 12 months follow-up. Postoperative marginal reflex distance-1 (MRD1) was assessed for functional outcomes as excellent, good, fair and poor. Eyelid contour and the difference in MRD1 between eyes were assessed for symmetrical cosmetic outcomes as excellent, good and poor. Demographic data, factors influencing surgical success and postoperative complications were analyzed.ResultsA total of 38 ptotic eyelids in 31 patients were included. Successful surgical outcomes (at least good functional and cosmetic outcomes) were achieved in 26 patients (83.87%) with the mean MRD1 of +3.61 ± 0.27 mm and +3.51 ± 0.17 mm at 1 week and 12 months after surgery, respectively. There were no significant differences in demographic and preoperative data between the successful and unsuccessful surgical outcome groups, mean preoperative ptosis measurements were 4.19 ± 0.20 mm versus 4.72 ± 0.36 mm (p = 0.242) and mean pre-operative LF were 3.16 ± 0.15 mm versus 2.29 ± 0.61 mm (p = 0.561), respectively. The only factor that significantly influenced the surgical success rate was the length of the resected levator muscle. The mean lengths in successful and unsuccessful groups were 18.15 ± 0.44 mm and 14.29 ± 0.94 mm, respectively (p = 0.011).ConclusionMaximal levator resection beyond Whitnall’s ligament is an effective procedure for severe simple congenital ptosis with poor LF. Refinement of surgical techniques and careful assessment of the optimal resected length for the levator muscle grants successful surgical outcomes.

Outcomes of Maximum Levator Resection in Severe Upper Eyelid Ptosis at a Tertiary Oculoplastic Service

Purpose: To investigate the surgical outcomes of maximum Levator resection in cases of severe upper eyelid ptosis at a tertiary oculoplastic service. Study Design: Interventional case series. Place and Duration of Study: Department of Ophthalmology, Lady Reading Hospital, Medical Teaching Hospital, Peshawar January 2013 to December 2017. Methods: One hundred and twenty three eyes of 107 patients, who underwent maximum levator resection for severe congenital ptosis were included. Patients with missing or incomplete notes, patients with previous ptosis surgery and ptosis other than congenital were excluded. Maximum levator resection of the muscle above the Whitnall ligament was performed under local/general anesthesia. All patients had a minimum of 6 months and maximum of 5 years followup. The postoperative complications were recorded and followed. Post operative followup was done at day one, week one and at four weekly intervals till the end of the study. Results: Out of 123 eyes, satisfactory results (excellent or good) were obtained in 111 (90.1%) eyes. Majority of the patients (56.09%) were females. Mean Preoperative Levator function was 2.3 ± 1.1mm. Mean Preoperative MRD1 was ?0.1 ± 1.5 mm and mean postoperative MRD1 was 3.9 ± 01.0 mm. The commonest complication was over correction which occurred in 5 (4.06%) cases, under correction in 4 (3.25%), crease abnormality in 2 (1.62%) cases and entropion was seen in only one (0.81%) case. Success rate was 90.1% at 6 months to 5-years followup. Key Words: Blepharoptosis; Levator resection; Levator function.

Improved Eyelid Muscle Tension Balance With Refined Frontalis Muscle Flap Suspension in the Treatment of Severe Ptosis.

The tension balance of the upper eyelid following ptosis repair is crucial to a successful postoperative outcome. To improve on existing surgical techniques, the authors developed a new refined frontalis muscle flap suspension (FMFS) for severe ptosis repair and explored the balancing effect between the orbicularis muscle and frontalis muscle following surgery. Forty-three patients (47 eyes) with a mean age of 6.07 ± 2.55 years old were diagnosed with severe congenital ptosis and underwent refined FMFS with complete orbicularis preservation between January 1, 2010 and December 31, 2017 in the Wenzhou Eye Hospital, Wenzhou, China. The outcomes measured include upper eyelid margin reflex distance (MRD1), degree of lagophthalmos, and cosmetic outcome (lash angle, eyelid contour, and crease). Surgical complications were also recorded. The preoperative mean MRD1 was -1.29 ± 0.88 mm and preoperative levator function was 1.87 ± 0.82 mm (ranged from 0 to 3.0 mm). Following surgery, lagophthalmos was observed in all cases in the first week with a mean palpebral fissure height of 1.68 ± 0.40 mm and diminished over 3 months. The MRD1 improved to +3.04 ± 0.68 mm at 6 months following surgery. All cases showed excellent cosmetic outcomes. There were no significant complications. The refined FMFS is a safe and reliable surgery in treating severe ptosis. The eye-closing power of the intact orbicularis muscle is sufficient at countering the lifting power of the frontalis muscle suspension, achieving a balanced blink mechanism and eyelid closure.

Surgical Observations of the Levator Aponeurosis Fibrotic Changes in Simple Congenital Ptosis Suggest Complex Pathogenesis.

To shed light upon the possible role of the levator aponeurosis (LA) developmental fibrotic changes as an added etiology for simple congenital ptosis, which causes limitation of the levator function (LF). This retrospective cohort study included patients with simple congenital ptosis who underwent skin approach LA resection as a primary intervention with an intraoperative photographic documentation of LA fibrotic changes. Preoperative demographics and clinical data were reviewed. The effect of LA fibrotic changes on the LF was assessed in different LA fibrotic changes with or without levator palpebrae superioris (LPS) muscle fatty infiltration. A total of 56 eyelids of 49 patients with a mean age (±SD) 6.7 (±3.2) years were enrolled in this study. The fibrotic changes of LA were observed as a sheet of fibrosis (19 eyelids) or fibrous bands (23 eyelids). Fatty infiltration of LPS was noticed in 28 eyelids, either with or without fibrotic changes of LA. Preoperative LF was diminished in LPS fatty infiltration compared with LA fibrotic sheets (P = 0.026). Postoperative LF improved significantly in both LA fibrotic sheets and LA fibrotic bands (9.4 ± 2.5 mm and 9.6 ± 2.8 mm, respectively) compared with LPS with fatty infiltration (6.4 ± 1.8 mm) (P = 0.004). Although our data are inconclusive due to lack of embryologic studies, the observed LA fibrotic changes may suggest a complex pathogenesis of simple congenital ptosis. The meticulous observation of the LA and the releasing of any adhesion or band to the surrounding structures could improve postoperative LF.

Lagophthalmos after congenital ptosis surgery: comparison between maximal levator resection and frontalis sling operation.

To compare postoperative lagophthalmos after maximal levator resection (MLR) and frontalis suspension (FS) in congenital ptosis patients with poor levator function (LF). A cross-sectional study was performed to compare postoperative outcomes in patients with preoperative LF ≤ 4 mm who had undergone MLR or FS at a single tertiary institution, and who had visited the outpatient clinic between February 2017 and August 2018. Main outcome measures were as follows: (1) Preoperative LF and margin reflex distance 1 (MRD1), (2) Postoperative MRD1, lagophthalmos and grade of superficial punctate keratopathy (SPK). Our study comprised 152 eyelids of 122 patients. There were 71 eyelids in the MLR group and 81 eyelids in the FS group. The MLR group had comparable mean postoperative MRD1 (2.8 ± 0.8 mm) to the FS with autogenous fascia lata (AFL) group (3.0 ± 0.7 mm), while the FS with preserved fascia lata (PFL) group had the lowest mean postoperative MRD1 (2.2 ± 1.0 mm). The PFL group had significantly less lagophthalmos (0.6 ± 1.0 mm) than the AFL (1.9 ± 1.4 mm) and maximal levator resection (1.9 ± 1.7 mm) groups. In the MLR group, there was no significant difference in postoperative surgical measurements between the LF 0-2 mm group and LF 2.5-4 mm group in terms of exposure keratopathy, degree of lagophthalmos and MRD1. MLR is an effective alternative to FS in congenital ptosis patients with poor levator function, with the risk of postoperative lagophthalmos related to postoperative MRD1 rather than preoperative LF.

Topical Corticosteroid Use Associated With Increased Degree of Ptosis and Rate of Ptosis Repair Failure.

To compare the degree of ptosis and the risk of ptosis repair failure among patients with and without a history of topical corticosteroid use. Retrospective, case-controlled study examining topical corticosteroid use among adults with ptosis who underwent external levator advancement/resection (ELR) or Müller muscle conjunctival resection with at least 3 months postoperative follow-up. Comparative statistical analyses of surgical outcomes were performed amongst patients with and without history of topical corticosteroid use. A total of 240 patients (406 eyelids) met study criteria, of which 36 patients (44 eyelids) had history of topical corticosteroid use. Mean preoperative margin reflex distance was 0.20 mm and 0.58 mm for topical corticosteroid and non-corticosteroids users (p = 0.01). Mean preoperative levator function was 9.78 mm and 10.38 mm for topical corticosteroid and non-corticosteroid users (p = 0.02). The rate of ptosis repair failure was 30% and 16% in patients with and without a history of topical corticosteroid use (odds ratio 2.25, 95% confidence interval 1.10-4.55; p = 0.03). The rate of recurrence per surgical type in eyelids with and without history of topical corticosteroid use was: external levator advancement/resection 11/27 (41%) and 48/266 (18%) (odds ratio = 3.12, confidence interval 1.36-7.15 0; p = 0.01); Müller muscle conjunctival resection 2/17 (12%) and 9/96 (9%) (odds ratio 1.29, confidence interval 0.25-6.56; p = 0.76). Topical corticosteroid use is associated with more severe presenting ptosis and increased rates of ptosis repair failure. Compared to Müller muscle conjunctival resection, there is a significantly higher rate of ptosis repair failure in patients undergoing external levator advancement/resection.

Postoperative Blepharoptosis After Modern Phacoemulsification Procedure

To investigate the frequency of transient (1month) and persistent (at least 6months) postoperative ptosis following clear corneal sutureless phacoemulsification and to analyze the factors affecting them. Cohort study. Patients who underwent phacoemulsification cataract surgery from October 2016 to June 2018 in a tertiary center were enrolled. Margin reflex distance 1 (MRD1), MRD2, and levator function were measured and facial photography was taken before, 1month, and at least 6months after the surgery. Clinical ptosis was defined as any postoperative drop of MRD1 and clinically significant ptosis as MRD1 drop of ≥2mm. Photo-based ptosis was assessed by a masked oculofacial plastic surgeon at the end of the study. A total of 234 patients (313 eyelids) were included. The majority of surgeries were performed by senior residents (65.5%, 205/313) and under topical anesthesia (78.0%, 244/313). Persistent clinical, clinically significant, and photo-based ptosis were 25.4% (71/279), 3.2% (9/279), and 3.3% (9/276). Eyelids with persistent postoperative ptosis showed a significantly (P= .03) lower preoperative levator function (13.9 vs 15.8mm). No other factor was significantly different between the eyelids with and without postoperative ptosis. Persistent clinically significant ptosis was observed in more than 3% of patients undergoing clear corneal sutureless phacoemulsification cataract surgery. It should be counseled preoperatively. Lower preoperative levator function was significantly associated with a higher frequency of postoperative ptosis. Duration of surgery, level of surgeons, and other variables did not have any significant effect on the frequency of postoperative ptosis.

Orbital Septum Fibrosis in Congenital Ptosis Correlates With Eyelid Function: A Clinicopathologic Study.

Congenital ptosis can threaten visual function and is usually treated with surgical correction. This study tests the hypothesis that congenital ptosis involves not only the levator muscle but also the orbital septum, which may tether the eyelid in the primary position. A retrospective chart review was performed on 30 patients (41 eyelids) with congenital ptosis who underwent surgical correction that included partial septum excision. Histologic analysis was performed by a masked pediatric pathologist, with grading of septal tissue disorganization and fibrosis based on standard histologic criteria. An independent comparison of histologic grading with clinical ptosis measures was then performed. Fifteen eyelids demonstrated significant septal fibrosis, 19 were mild, and 7 were not fibrotic. Thirty-six eyelids demonstrated histologic disorganization. Mildly fibrotic eyelids were found to have reduced preoperative levator function than those that were not fibrotic (2.84 ± 1.92 vs. 9.57 ± 4.76 mm; p < 0.0001). Samples that demonstrated significant fibrosis were also found to have reduced preoperative levator function (4.67 ± 2.12 vs. 9.57 ± 4.76 mm; p = 0.0007). Histologically disorganized samples were also found to have a lower preoperative levator function (9.50 ± 6.04 vs. 3.99 ± 2.49; p = 0.0052). Orbital septae in patients with congenital ptosis demonstrate histologic disorganization and fibrosis. When decreased levator function is observed clinically, septal fibrosis and/or disorganization is likely present. These observations suggest that debulking the fibrotic septum during congenital ptosis surgery may improve outcomes by releasing the eyelid from its congenitally tethered position, improving eyelid elasticity.

Postoperative levator function change in patients with unilateral myogenic versus aponeurotic blepharoptosis

To compare the change in levator function (LF) after levator resection in patients with unilateral myogenic (MP) and aponeurotic ptosis (AP). In a prospective study, patients of >5 years old were included from June 2015 to April 2017. Other types of ptosis, associated strabismus and previous eyelid surgery were excluded. Eyelid examination and photography were performed before and at least 6 months after surgery. Success was defined as Margin reflex distance 1 (MRD1) of within 0.5 mm of the unoperated side. All procedures (levator resection) were performed by or under supervision of one surgeon. There were 58 patients in the MP (mean age: 19.2 years) and 20 in the AP (mean age: 49.5) group with median follow up of 10 months. LF was significantly improved from 5.8 to 7.3 mm in the MP and from 11.8 to 13.6 mm in the AP group. LF improvement was not observed in 17.2% of MP and 25% of AP group (P = 0.5). Mean preoperative LF was significantly (Odd ratio=1.8) higher in patients with than without LF improvement in the MP group. It was significantly reverse in the AP group (Odd ratio=0.38). A significantly positive (r = 0.30) and negative (r=-0.72) correlations were observed between preoperative LF and LF improvement in the MP and AP groups, respectively. Success was observed in 90% of AP and 84.5% of MP group. In order of frequency, undercorrection, overcorrection, and contour abnormality were the reasons for failure. No variable significantly affected the success rate in either group. Majority of MP and AP showed postoperative LF improvement. While higher preoperative LF was significantly correlated with LF improvement in the MP, it was reverse in the AP group. Success rate was not significantly different between the groups and no factor significantly affected the success in either group.

Surgical intervention for paediatric blepharoptosis: a 6-year case series.

To present our experience of paediatric blepharoptosis in a tertiary referral centre and evaluate the effectiveness of surgical intervention. A retrospective cohort study of all children receiving surgical blepharoptosis correction between 1/1/10 and 29/2/16. Children with pre-operative levator function (LF) ≥ 7mm received levator resection, those with LF ≤ 4mm received brow suspension, and in those children with LF of 5-6mm, either levator resection or brow suspension was chosen depending on the degree of frontalis recruitment. Ninety-five children (109 eyes, 64 boys) underwent blepharoptosis surgery within the study period. Mean (range) age at surgery was 5.9 (1.2-12.5)years. Seventy-nine (83.2%) had simple levator maldevelopment. Fifteen children were excluded due to inadequate follow-up. Of the remaining 80 children, 41 (51.2%) underwent levator resection, 27 (33.8%) underwent fascia lata brow suspension, and twelve (15.0%) underwent mersilene mesh brow suspension. Margin reflex distance-1 was greatest at 6-week follow-up with a small "lid drop" by 6-month follow-up in both the levator resection (0.9mm pre-operatively, 3.1mm at 6-week follow-up, 2.6mm at 6-month follow-up) and fascia lata brow suspension (0.3mm, 2.5mm, 2.2mm) groups. No immediate complications, and only two serious post-operative complications, were noted. One case of residual blepharoptosis was re-operated (fascia lata brow suspension). Surgical correction of paediatric blepharoptosis is safe and, after an observed lid drop between 6-week and 6-month follow-up (not seen in the mersilene mesh brow suspension group), effect appears to be maintained to 6months and beyond. Readily accessible orthoptic assessment would help identify children at risk of amblyopia, both pre-operatively and post-operatively.

Small-incision levator resection for correction of congenital ptosis: a prospective study.

To determine the rate of success of small-incision levator resection technique for correction of congenital ptosis. Patients with congenital ptosis who were candidates for levator resection were enrolled if their levator function was not poor (< 5mm). Incisions were made on upper eyelid crease with a length of 10-12mm. After resection of adequate length of levator muscle, two sutures were used to fix it to tarsal plate. Sliding the incision to medial and lateral sides provided a wider field of access to allow the surgeon to place the sutures above nasal and temporal borders of limbus. Success was defined as margin reflex distance-1 (MRD-1) ≥ 3mm and inter-eyelid difference of MRD-1 less than 1mm, which was considered excellent if inter-eyelid difference was < 0.5mm and good if the latter parameter was between 0.5 and 1mm. Fifty eyes of 47 congenital ptosis cases (16 males and 31 females) were included. Average age was 21.7 ± 9.7years (range, 3-44years). Mean preoperative levator function and MRD-1 were 11.26 ± 2.79 and 1.78 ± 0.92mm, respectively, while postoperative MRD-1 increased to 3.95 ± 0.82mm (P < 0.001). The result was failure (undercorrection) in 12 cases (25.5%), good in 9 patients (19.2%), and excellent in 26 cases (55.3%). Small-incision levator resection has previously been studied for correction of aponeurotic ptosis and proved to yield successful outcome. The findings of this study suggest that small-incision technique can be effectively used in correction of congenital ptosis, as well.

The Value of the Frontalis Suspension Procedure as a Repeat Intervention in Congenital Blepharoptosis.

To evaluate the therapeutic benefits of frontalis suspension as a repeat intervention in congenital blepharoptosis. Pediatric patients diagnosed as having congenital ptosis who had at least 2 years of postoperative follow-up were included in this retrospective study. A successful outcome was defined as a postoperative margin-reflex distance of 3 mm or greater. The chi-square, Student's t, and Mann-Whitney U tests were used in comparisons. Eighty-four eyes of 77 patients with a follow-up period of 8.4 ± 0.7 years were included. The initial surgery was levator resection in 29 (34.5%) eyes and frontalis suspension in 55 (65.5%) eyes. Frontalis suspension was performed for all repeat interventions (n = 20). Surgical success was achieved in 61.9% of patients with single surgery (75.9% for levator resection vs 54.5% for frontalis suspension; P = .06) and in 77.4% of patients following repeated surgeries (93.1% vs 69.1% for patients who initially underwent levator resection vs frontalis suspension, respectively; P = .012). A higher success rate was associated with better preoperative levator function (P = .01) and a higher margin-reflex distance (P = .004), and was inversely proportional to ptosis severity (P = .04). Frontalis suspension as a repeat intervention for congenital blepharoptosis is associated with a further increase in long-term anatomic success rates and should be considered when initial procedures fail or remain inadequate. [J Pediatr Ophthalmol Strabismus. 2017;54(5):320-323.].

Analysis of Levator Function and Ptosis Severity in Involutional Blepharoptosis.

Involutional blepharoptosis is the most common type of acquired blepharoptosis. The etiology is believed to be the degeneration of the levator aponeurosis, and levator superioris muscle function was believed to be normal. However, there are a few studies analyzing levator function (LF) in involutional blepharoptosis. Our study aimed to access the LF abnormality in involutional blepharoptosis and analyze the correlation between LF and ptosis severity in involutional blepharoptosis in Taiwan. We reviewed the medical records of patients who underwent ptosis correction surgery between October 2011 and December 2015 after receiving a diagnosis of involutional blepharoptosis. This study examined patient sex and age, preoperative LF, margin reflex distance of the upper eyelid (MRD1), and ptosis severity. Linear regression was performed for statistical analysis. Levator muscle specimen was sent for pathologic examination. We analyzed 231 eyelids of 126 patients. Average MRD1 was 0.43 ± 2.15 mm. Average LF was 14.30 ± 2.51 mm. Overall, 77.1% (178/231) of involutional blepharoptotic eyelids had normal LF (more than 12 mm). Forty-three (18.6%) of 231 were good (10-12 mm), and 10 (4.3%) of 231 were fair (6-9 mm). No patients with poor levator function (≤5 mm) were observed in our case series. A positive correlation between LF and MRD1 was observed after statistical analysis. On average, a 0.6-mm reduction in LF was observed for each 1.0-mm decrease in MRD1. Fat infiltration in levator muscle is observed both grossly and microscopically in most cases with varied degrees. Levator function and MRD1 were positively correlated in patients with involutional blepharoptosis. In our study, 77.1% (178/231) of eyelids had normal levator function, which meant there was 23.0% (53/231) of eyelids had abnormal LF, in contrast to current literature. Fat infiltration was common in our series. In Asian involutional blepharoptosis, LF was not always excellent and it had positive correlation with ptosis severity.

Maximal levator resection in unilateral congenital ptosis with poor levator function

Background/aimsSurgical treatments for the correction of congenital ptosis with poor levator function, including frontalis suspension or maximal levator resection, remain controversial. We evaluated the postoperative surgical and cosmetic outcomes after...

Improvement in levator function after anterior levator resection for the treatment of congenital ptosis.

To evaluate the surgical outcome of levator resection in congenital ptosis, and to assess the change in levator function (LF) after surgery, as well as its effect on surgical outcomes. The charts of patients who underwent an anterior levator resection for congenital ptosis between January 2010 and February 2013 were retrospectively reviewed. Preoperative and postoperative grades of blepharoptosis, margin-reflex distance, LF, and reoperation status were noted, and postoperative outcomes were evaluated. A total of 42 eyelids of 37 patients were included of which 32 eyelids (76.2%) had severe ptosis while 10 eyelids (23.8%) had moderate ptosis. The mean follow up was 11.0 ± 7.2 months. The overall success rate after initial surgery was 78.6%, and undercorrection was the leading course of surgical failure, with a rate of 14.3% (6 eyelids) at the final visit. Lagophthalmus and/or overcorrection occurred in 7.1% (3 eyelids) at the final visit, respectively. The mean preoperative LF was 6.8 mm ± 3.1 mm, which increased postoperatively to 8.7 mm ± 3.4 mm (p < 0.05) at month 1 and 9.6 mm ± 3.8 mm (p < 0.05) at the final visit. The mean LF improvement following surgery was 2.9 mm ± 2.2 mm. The levator resection surgery was observed to be an effective treatment for congenital ptosis, including severe ptosis with poor LF. Levator resection resulted in substantial improvement of postoperative levator muscle functioning, which might have an additive effect on the surgical success, especially for those with poor LF.

Surgical Correction of Blepharoptosis Using a Modified Levator Aponeurosis–Müller Muscle Complex Reinsertion Technique

The purpose of this study was to evaluate the outcomes after ptosis correction surgery using a modified levator aponeurosis-Müller muscle complex reinsertion technique. In this clinical study, 75 eyelids of 49 patients with congenital blepharoptosis were treated with the modified technique. The results, including complications, were followed up and evaluated. Operation was performed via anterior transcutaneous incision. After separating the preseptal orbicularis oculi muscle, the levator complex, including Müller muscle and the levator aponeurosis, was visualized. The levator complex was cut into 2 parts at the top of the conjunctival fornix to create an upper portion and a lower portion. The detached lower portion of the complex flap combined with the tarsal plate was advanced superiorly and reinserted into the posterior aspect of the upper portion of the complex flap by using 3 horizontal mattress sutures. Preoperative ptosis severity was compared with the degree of ptosis correction using the Cochran-Mantel-Haenszel test. Preoperative levator function was compared with the degree of ptosis correction and the postoperative levator function using Fisher exact test for paired data. Sufficient postoperative correction of ptosis was achieved in 78.7% of eyelids. Postoperative levator function of more than 4 mm was achieved in 82.7% of all eyelids that underwent surgery. We conclude that the modified levator aponeurosis-Müller muscle complex reinsertion technique is effective for correcting congenital blepharoptosis, especially in patients with fair to good (>4 mm) preoperative levator function.

Is Hering's Law as Important in Congenital Blepharoptosis as in Acquired Ptosis?

Although Hering's law has significant importance in the planning and outcomes of eyelid surgery, it has not been applied in all cases of ptosis. The authors evaluate whether cases of unilateral congenital ptosis require surgery on the contralateral eyelid, in keeping with Hering's law. The records of 35 consecutive patients with unilateral congenital ptosis who had surgical repair between 2007 and 2012 were retrospectively analyzed. All patients underwent either levator resection or frontalis sling surgery. Preoperative and postoperative clinical documents and photographs were evaluated for each case, including preoperative Hering's dependence and postoperative measurements of the change in position of the nonoperated eyelid. There were 19 women and 16 men, and the average patient age was 9.7 ± 10 years. The mean preoperative levator function and marginal reflex distance were 6.7 ± 4.7 mm and 0.3 ± 0.47 mm, respectively. There were significant differences in age, preoperative levator function, and marginal reflex distance between patients who underwent levator resection and those who had frontalis sling surgery. In all patients, the preoperative Hering's dependence of eyelid position did not show any decrease, and the position of the contralateral eyelid postoperatively did not differ from the baseline position. This research shows that Hering's law does not apply to cases of congenital ptosis. This is likely due to the fibrotic levator palpebrae muscle and its special innervations. Thus, it is not necessary to perform levator resection or a frontalis sling operation on the unaffected eyelid.