Ptosis Of Upper Eyelid Research Articles

The prevalence of ptosis in an Iranian adult population

PurposeTo determine upper eyelid ptosis prevalence and some related factors in 44- to 69-year-olds of Shahroud in the north of Iran. MethodsIn 2009, using multi-stage cluster sampling, 300 clusters of 40–64-year-olds were selected in Shahroud city, and all 5190 participants were invited to be re-examined in 5 years (2014). The current report is the second phase of the study in which 4737 (91.3%) people participated and underwent vision tests, slit lamp examination, biometry, and ophthalmoscopy in 2014. Upper eyelid ptosis was determined by an ophthalmologist. ResultsThe prevalence of upper eyelid ptosis was 4.7% [95% confidence interval (CI): 4.1–5.4]; 5.2% in women and in 4.0% in men. The prevalence of bilateral and unilateral ptosis was 1.3% (95% CI: 1.0–1.7) and 3.4% (95% CI: 2.8–4.0), respectively. The observed prevalence of ptosis was 3.1% in the 45- to 49-year age group and 5.8% in 65- to 69-year-olds. The prevalence of ptosis increased with age. In the multiple logistic regression model, ptosis prevalence correlated with older age, diabetes (odds ratio = 1.53, 95% CI: 1.16–2.02) and hypertension (odds ratio = 1.41, 95% CI: 1.03–2.92). Mean corneal astigmatism was 1.02 (95%C]: 0.87–1.18) diopter in ptotic eyes and 0.87 (95% CI: 0.84–0.89) diopter in non-ptotic eyes (p = 0.013). ConclusionsThe present report provides valuable information on the prevalence of ptosis in a population of 45-to 69-year-olds. The prevalence of ptosis in this study was considerably high and significantly increased with age.

Surface electromyography analysis of blepharoptosis correction by transconjunctival incisions

Upper eyelid movement depends on the antagonistic actions of orbicularis oculi muscle and levator aponeurosis. Blepharoptosis is an abnormal drooping of upper eyelid margin with the eye in primary position of gaze. Transconjunctival incisions for upper eyelid ptosis correction have been a well-developed technique. Conventional prognosis however depends on clinical observations and lacks of quantitatively analysis for the eyelid muscle controlling. This study examines the possibility of using the assessments of temporal correlation in surface electromyography (SEMG) as a quantitative description for the change of muscle controlling after operation. Eyelid SEMG was measured from patients with blepharoptosis preoperatively and postoperatively, as well as, for comparative study, from young and aged normal subjects. The data were analyzed using the detrended fluctuation analysis method. The results show that the temporal correlation of the SEMG signals can be characterized by two indices associated with the correlation properties in short and long time scales demarcated at 3ms, corresponding to the time scale of neural response. Aging causes degradation of the correlation properties at both time scales, and patient group likely possess more serious correlation degradation in long-time regime which was improved moderately by the ptosis corrections. We propose that the temporal correlation in SEMG signals may be regarded as an indicator for evaluating the performance of eyelid muscle controlling in postoperative recovery.

Sarcoidosis. Debut as orbital pseudotumour

Case report78-Year-old female patient being investigated for a left orbital pseudotumour of 17 days onset. She had proptosis, pain, with no limitation of eye movements, periorbital edema, and upper eyelid ptosis, compatible with an orbital pseudotumour. The MRI showed an upper outer left orbital mass adjacent to the side of eyeball and an increase in soft tissue at the level of lacrimal gland. The histopathology study of an eyelid lesion demonstrated the presence of non-caseating granulomas. DiscussionA definitive diagnosis of orbital sarcoidosis was made. Oral treatment with corticosteroids and methotrexate achieved gradual control of the disease.

Perception of Age, Attractiveness, and Tiredness After Isolated and Combined Facial Subunit Aging.

Patients often seek help to redress aging that affects various regions of the face (subunits). The purpose of this study was to determine how aging of different facial subunits impacts perception of age, attractiveness, and tiredness. Frontal and lateral view facial photographs of a middle-aged woman were modified using imaging software to independently age different facial features. Sixty-six subjects were administered with a questionnaire, and presented with a baseline unmodified picture and others containing different individual or grouped aging of facial subunits. Test subjects were asked to estimate the age of the subject in the image and quantify (0-10 scale) how "tired" and "attractive" they appeared. Facial subunits were organized following rank assignment regarding impact on perception of age, attractiveness, and tiredness. The correlation coefficient between age and attractiveness had a strong inverse relationship of approximately -0.95 in both lateral and frontal views. From most to least impact in age, the rank assignment for frontal view facial subunits was full facial aging, middle third, lower third, upper third, vertical lip rhytides, horizontal forehead rhytides, jowls, upper eyelid ptosis, loss of malar volume, lower lid fat herniation, deepening glabellar furrows, and deepening nasolabial folds. From most to least impact in age, the rank assignment for lateral view facial subunits was severe neck ptosis, jowls, moderate neck ptosis, vertical lip rhytides, crow's feet, lower lid fat herniation, loss of malar volume, and elongated earlobe. This study provides a preliminary template for further research to determine which anatomical subunit will have the most substantial effect on an aged appearance, as well as on the perception of tiredness and attractiveness. 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.

Intra-Arterial Chemotherapy for Retinoblastoma: A Single-Center Experience

Background: Studies conducted in recent years have reported promising results regarding the treatment of retinoblastoma with the intra-arterial use of melphalan. In the present study, we intended to report the results of intra-arterial chemotherapy with melphalan (IACT) in the treatment of newly diagnosed or relapsed-refractory retinoblastoma patients at the Department of Pediatric Oncology of Hacettepe University, Ankara, Turkey. Materials and Methods: This was a retrospective study of patients with intraocular retinoblastoma who were treated with IACT from December 2011 to May 2014. A total of 56 eyes of 46 consecutive patients (30 males and 16 females) were included in the study. Forty-four eyes received systemic chemotherapy upon diagnosis (systemic chemotherapy group, SCG), and 12 eyes were those of newly diagnosed patients (primary intra-arterial melphalan group, PIAG). The choice of the IACT dose was based on age. Tumor control and globe salvage with IACT were analyzed. Complete blood counts were examined 7 days after the IACT for systemic toxicity. Ocular toxicities such as proptosis, eyelid edema, ocular motility, and retinal and optic atrophy were assessed by an ocular oncologist with regular ophthalmologic examinations. Results: Enucleation was avoided overall in 66% (37/56) of the eyes, including 75% (9/12) in the PIAG and 64% (28/44) in the SCG patients. The 1-year enucleation-free survival rate was 56.7% at a median follow-up time of 11.9 months (range 0.27-27.6). IACT was administered in a total of 124 cycles (ranging from 1 to 7 cycles, mean 2.3). The responses were as follows: regression of the retinal tumor in 27 eyes and improvements in vitreous seeding in 5 of 15 eyes. The further treatment requirements after IACT were as follows: enucleation in 19 eyes (10 with vitreous seeding), radiotherapy in 3 eyes, systemic chemotherapy in 1 eye, and local therapy in 1 eye. No severe systemic side effects occurred. Transient swelling of the eyelids (22 patients), conjunctival chemosis (12 patients), upper eyelid ptosis (5 patients), redness over the frontal area (3 patients), limitation of ocular motility (3 patients) and mild proptosis (1 patient) were detected. Retinal pigment epithelial alterations (30 patients) and optic atrophy (3 patients) were seen in the late follow-up. Conclusions: Globe salvage and avoidance of radiotherapy may be achieved by IACT with limited toxicity. This treatment is efficient, repeatable and safe.

Sarcoidosis. Comienzo como pseudotumor orbitario

Case report78 year-old female patient being investigated for a left orbital pseudotumour of 17 days onset. She had proptosis, pain, with no limitation of eye movements, periorbital oedema, and upper eyelid ptosis, compatible with an orbital pseudotumour. The MRI showed an upper outer left orbital mass adjacent to the side of eyeball and an increase in soft tissue at the level of lacrimal gland. The histopathology study of an eyelid lesion demonstrated the presence of non-caseating granulomas. DiscussionA definitive diagnosis of orbital sarcoidosis was made. Oral treatment with corticosteroids and methotrexate achieved gradual control of the disease.

Persistence of Upper Blepharoptosis After Cosmetic Botulinum Toxin Type A.

Upper eyelid ptosis after cosmetic botulinum toxin is generally considered short-lived and responsive to apraclonidine ophthalmic drops. The authors present a series with persistent ptosis. To report a series of patients with persistent upper eyelid ptosis after cosmetic botulinum toxin. A retrospective case review series of 7 patients referred for management after developing visually significant upper eyelid ptosis after cosmetic botulinum toxin type A treatment. Patients in this series experienced persistent visually significant ptosis after cosmetic botulinum toxin lasting from 6 weeks to 13 months. Six of the 7 patients were treated with apraclonidine ophthalmic solution. Apraclonidine drops appeared to be clinically effective within 4 to 6 weeks of the resolution of ptosis. Upper eyelid ptosis after cosmetic botulinum toxin can persist for many months after treatment. Based on this series, the authors propose that apraclonidine drops can be used at the time of initial assessment to predict the relative longevity of ptosis after cosmetic botulinum toxin treatment (Level 4 evidence recommendation). After a 1-week trial, responders can be advised that ptosis is likely to resolve in 4 to 6 weeks. Nonresponders should be counseled that resolution may take longer than 6 weeks.

Mueller's Muscle Conjunctival Resection With Skin-Only Blepharoplasty: Effects on Eyelid and Eyebrow Position.

To determine the effect of concurrent blepharoplasty and Mueller's muscle conjunctival resection (MMCR) surgery on eyelid position and eyebrow height. Clinical data from 274 eyes that met inclusion criteria for this study were reviewed. Mueller's muscle conjunctival resection surgery was performed alone in 198 eyes and was performed with concurrent blepharoplasty in 76 cases. In this study blepharoplasty consisted of only skin removal, leaving the muscle, fat, and tarsus intact. Preoperative and postoperative pupil to eyebrow, and eyelid margin to eyebrow distances were calculated and compared. Preoperative margin reflex distance 1 (MRD1) was similar for both groups of patients (p > 0.05) as was the postoperative MRD1 (p > 0.05). The change in MRD1 was similar between patients undergoing MMCR alone versus those undergoing MMCR with blepharoplasty (1.5 mm vs. 1.3 mm, respectively, p = 0.36). For similar amounts of tissue resection, the postoperative change in MRD1 was similar for patients undergoing MMCR-only surgery and MMCR with blepharoplasty (p > 0.05). Eyebrow height significantly decreased following both MMCR with blepharoplasty (0.73 mm, p < 0.05) and MMCR-only surgery (0.87 mm, p < 0.05), and this change in eyebrow height was not significantly different between the 2 groups. Combining MMCR surgery with skin-only blepharoplasty does not significantly alter eyelid height when compared with MMCR surgery alone for the correction of upper eyelid ptosis. This may assist in preoperative planning for combined MMCR with skin-only blepharoplasty.

Environmental factors that contribute to upper eyelid ptosis: a study of identical twins.

Current literature provides little information about the impact of environmental exposures on the severity of acquired blepharoptosis. The authors assessed environmental factors that may contribute to eyelid ptosis in a population of identical twins. Photographs of 286 sets of twins from a prospectively collected database from 2008 to 2010 were reviewed. The authors identified 96 sets of identical twins (192 individual persons) who had differing severity of ptosis. Digital photographs were analyzed, and the degree of ptosis was measured in each eye of every subject. The external factors that could potentially contribute to blepharoptosis were taken into consideration. The authors then assessed the correlations of 9 different environmental risk factors with ptosis. Generalized linear mixed model were constructed to determine the associations of ptosis measurements with environmental risk factors obtained from the subject survey database. The mean level of upper eyelid ptosis in the study population was 1.1 mm. The mean difference in ptosis between twins was 0.5 mm. Wearing contact lenses, either hard or soft, was significantly associated with ptosis. The mean ptosis measurement among twins who did not wear contact lenses was 1.0 mm; for those who wore soft contact lenses, the mean was 1.41 mm, and for those who wore hard contact lenses, the mean was 1.84 mm. Acquired ptosis is not linked to body mass index, smoking behavior, sun exposure, alcohol use, work stress, or sleep. Wearing either hard or soft lenses was associated with an increased risk of ptosis. These influences are independent of genetic predisposition. 3 Diagnostic.

Suspension surgery with autogenous fascia lata via a less invasive modification of the Crawford method on 85 patients with congenital severe eyelid ptosis

Background. Autogenous fascia lata is considered the gold standard for frontalis suspension surgery to correct severe congenital upper eyelid ptosis. Methods. This study evaluated the efficacy of a less invasive modification of the standard technique described by Crawford. A total of 85 patients with severe congenital ptosis were enrolled in this study and submitted to surgical correction by frontalis suspension using autogenous fascia lata. Among these patients, 51 had previously undergone ptosis correction using other surgical techniques. The final lid level and contour were evaluated in addition to complications, such as lagophthalmos and ptosis recurrences. Results. Overall, the final results were evaluated as good in 71 of the cases, whereas 11 cases were graded as satisfactory and three cases as poor according to the success criteria. The average increase in eyelid height, measured as the marginal reflex distance (MRD), was 2.9 mm. The best results were obtained in the group of patients with no previous eyelid surgeries. The examples of poor results could be attributed to lagophthalmos and were all confined to the group of patients with a previously failed surgery that employed synthetic suspension materials and levator shortening procedures. No recurrences were observed during the follow-up interval, which lasted an average of 6.4 months (range = 2–59 months). Conclusions. This technique allows a safe surgery with an overall high rate of success. This surgery is also safe and successful in cases of congenital ptosis with associated abnormalities, such as blepharophimosis, and in cases that require secondary ptosis repair.

Adult orbital xanthogranulomas: clinical features and management.

Adult-onset asthma with periocular xanthogranuloma and adult-onset xanthogranuloma are 2 rare subtypes of non-Langerhans cell histiocytic disorder and much remains unknown regarding optimal treatment. The authors describe their experience in the management of these 2 disease subtypes. This is a retrospective case series with histopathologically proven orbital xanthogranuloma over a period of 12 years. Clinical, imaging, and histopathologic features; associated systemic conditions; treatment modality; and outcome during follow-up of 6 adult patients who had adult-onset asthma with periocular xanthogranuloma and adult-onset xanthogranuloma were reviewed. The age range was 29-75 years (median 56 years). The duration of symptoms and signs varied from 10 months to 9 years. All patients had bilateral and asymmetric involvement. Palpebral swelling with yellow discoloration and upper eyelid ptosis were the most common signs. Adult-onset asthma was present in 2 patients. Imaging studies demonstrated ill-defined infiltrative lesions involving the preseptal area, lacrimal glands, extraocular muscles, retrobulbar fat, and optic nerves. The median follow-up was 50 months. Complete regression of all clinical signs was obtained at 8 months, whereas imaging findings disappeared at 18 months with treatment. No recurrence was observed. Treatment consisting of debulking as much affected soft tissue as possible followed by a 3-day course of intravenous pulse methylprednisolone administration and then by oral prednisone for at least 6 months may provide adequate regression of the granulomas without recurrence and satisfactory cosmesis in patients with adult orbital xanthogranuloma with and without asthma.

Muller′s muscle-conjunctival resection for blepharoptosis repair

Objective The aim of this study was to evaluate the results of Muller's muscle-conjunctival resection in the treatment of mild-to-moderate ptosis with fair-to-good levator function. Background Muller's muscle-conjunctival resection, which was originally described by Fasanella and Servat and later modified by Putterman and Urist, has traditionally been performed for correction of mild-to-moderate upper eyelid ptosis, resulting in improved eyelid height. Patients and methods A prospective nonrandomized study was conducted on patients attending the Outpatient Clinic of Ophthalmology Department in Menoufia University Hospital during the period of study from May 2013 to October 2014. This study was conducted on 20 eyes of 20 patients with mild-to-moderate ptosis with fair-to-good levator function. Muller's muscle-conjunctival resection was performed for all cases, and the patients were followed up for 6 months. Results Success of the operation was determined by means of postoperative eyelid elevation. Patients were divided into three categories: (a) successful (eyelid elevated to cover 2 mm of the cornea or within 0.5 mm of this level), which included 12 eyelids (60%); (b) accepted (within 1 mm of normal eyelid level, which covers 2 mm of the cornea), which included eight eyelids (40%); and (c) failed (uncorrected 0%). Conclusion Muller's muscle-conjunctival resection surgery has high success rate in treating mild-to-moderate ptosis with fair-to-good levator function. It also has few and mild complications, with the advantage of good cosmetic results due to avoidance of cutaneous scar, and results in good eyelid contour.

Prostaglandin-associated periorbitopathy in latanoprost users.

PurposeWe investigated the incidence of prostaglandin-associated periorbitopathy (PAP) in subjects with glaucoma treated with latanoprost ophthalmic solution.Subjects and methodsOne eye and the forehead in 22 subjects were evaluated. All patients had used latanoprost for more than 1 year (range, 12 to 45 months; mean, 26.0 months) and were prostaglandin F2α analogue treatment-naïve. Digital photographs of the subjects obtained before latanoprost therapy and at the last examination were compared retrospectively. Four signs of PAP (deepening of the upper eyelid sulcus (DUES), upper eyelid ptosis, flattening of the lower eyelid bags, and inferior scleral show) and supplemental side effects around the eyelids (eyelash growth, poliosis, and eyelid pigmentation) were judged to be negative or positive by three independent observers. If the observers unanimously rated a sign as positive, the result was defined as positive.ResultsTwelve subjects (54.5%) had no apparent signs. Three subjects were judged to have DUES (13.6%), and two subjects each were judged to have flattening of the lower eyelid bags and eyelid pigmentation (9.0%). The other signs were judged as positive in only one subject each, respectively (4.5%). A univariate logistic regression analysis showed no significant associations between any of the signs and age, sex, or the duration of therapy.ConclusionLatanoprost induced DUES, upper eyelid ptosis, flattening of the lower eyelid bags, inferior scleral show, and supplemental side effects around the eyelids; however, the rates of such occurrence might be relatively low.

Perception of Age, Tiredness and Attractiveness after Isolated and Combined Facial Subunit Aging

PURPOSE: The purpose of the present study was to determine how aging of different facial subunits, either isolated or combined, would impact perception of age, attractiveness and tiredness. METHOD: A standardized frontal view facial photograph of a middle-aged woman was modified using imaging software to independently age different facial features. Sixty-six health care workers were administered a questionnaire, and presented with 15 sets of images, one baseline unmodified picture and other images containing different individual or grouped aging of facial subunits. Subjects were asked to estimate the age of the subject in the image and quantify (0-10 scale) how “tired” and “attractive” they appeared. Results were compared with scores for the baseline image. Repeated measurement one-way ANOVA and post hoc Turkey analysis were used to compare multiple variables. Facial subunits were organized following rank assignment regarding impact on perception of age, attractiveness and tiredness. RESULTS: The correlation coefficient between age and attractiveness had a strong inverse relationship of -0.95 confirming that age had a dependant impact on perceived attractiveness. There is also an inversely proportional relationship between tiredness and attractiveness with a correlation coefficient of -0.82. From most to least impact in age, the rank assignment for facial subunits was: full facial aging, middle third, lower third, upper third, vertical lip lines, horizontal forehead lines, jowls, upper eyelid ptosis, loss of malar volume, lower lid fat herniation, deepening glabellar furrows, deepening nasolabial folds. Statistically, brow ptosis and crow’s feet did not impact age. Regarding attractiveness, the rank assignment was: full facial aging, middle third, upper third, lower third, upper eyelid ptosis, jowls, lower lid fat herniation, deepening glabellar furrows, brow ptosis, horizontal forehead lines, vertical lip lines, loss of malar volume. Statistically, deepening of nasolabial folds and crow’s feet did not influence attractiveness. Regarding tiredness, the rank assignment was: full facial aging, middle third, lower lid fat herniation, upper eyelid ptosis, loss of malar volume, upper third. Statistically, lower third, jowls, deepening glabellar furrows, brow ptosis, horizontal forehead lines, vertical lip lines, deepening of nasolabial folds and crow’s feet did not influence tiredness. CONCLUSION: We provide a ranking system based on multiple variable statistical analyses, which can help predict which anatomical subunit will have the most substantial effect on an aged appearance.

Factors contributing to facial asymmetry in identical twins.

This study examines the potential contributions of environmental factors to variations in facial symmetry between identical twins. Identical male and female twins were recruited from the Twins Days Festival in 2009 and 2010. Subjects independently completed a comprehensive questionnaire on their medical and personal history, and then posed for digital facial photography from several different angles. Eight facial features from these photographs were measured using Adobe Photoshop, and these facial features were then analyzed against survey responses between twins through multivariate regressions. A total of 147 pairs of identical twins were included. Twins who slept primarily prone had greater nasal midline deviation (p = 0.047) and oral commissure asymmetry (p = 0.027). Tooth extractions were significantly associated with canting of the plane of occlusion (p = 0.043), and use of dentures was associated with nasal midline deviation (p = 0.032) and oral commissure asymmetry (p = 0.007). Smoking was associated with canting of the plane of occlusion (p = 0.049) and upper eyelid ptosis (p = 0.023). Lastly, headaches were also associated with nasal midline deviation (p = 0.024). Exogenous factors such as prone sleep position, tooth extractions, dentures, and smoking are significant risk factors for facial asymmetry. Risk, II.

Comparison of Blepharoptosis Correction Using Müller-aponeurosis Composite Flap Advancement and Frontalis Muscle Transfer.

Treatments for severe blepharoptosis are well documented and include the most common operations for restoring upper eyelid ptosis, which are levator surgery and frontal muscle transfers; however, the choice of treatment is still controversial. There are different approaches to the restoration of upper eyelid ptosis, and the choice will be based on ptosis severity and the surgeon's skill and experience. Two hundred and fourteen patients presenting with a levator function of between 2 and 4 mm received ptosis correction between 1991 and 2010 at our clinic. Of these, 71 patients underwent Müller aponeurosis composite flap advancement for correction of 89 eyelids, and frontalis muscle transfer was performed on 143 patients (217 eyelids). Postoperative results were evaluated with an average follow-up period of 23 months. The preoperative average for marginal reflex distance (MRD1) in the Müller aponeurosis composite flap advancement group was 1.25 mm, and in the frontal muscle transfer group, it was 0.59 mm. The area of corneal exposure (ACE) was 57.2% in the Müller aponeurosis composite flap advancement group and 53.6% in the frontal muscle transfer group. The postoperative average distance was not significantly different for the 2 techniques. In the Müller aponeurosis composite flap advancement group, MRD1 was 2.7 mm and ACE was improved to 73.5%. In the frontal muscle transfer group, MRD1 was 2.3 mm and ACE was 71.2%. Undercorrection and eyelid asymmetry were the most frequently observed postoperative complications for both techniques. In our study, we confirmed that Müller aponeurosis composite flap advancement and the frontalis transfer technique are both effective in the correction of severe blepharoptosis; our results showed no significant differences between the 2 techniques.

Five-Year Follow-Up of a 30-Month Trial of Stability of Silicone Band Frontalis Suspension for the Treatment of Severe Unilateral Upper Eyelid Ptosis in Infants

Purpose: To evaluate the five-year stability of frontalis suspension of the upper eyelid with a silicone band for the treatment of severe congenital ptosis in infants. Methods: Chart review of pediatric patients with a follow-up of five years after unilateral frontalis suspension with silicone band was reviewed. Margin-reflex distance (MRD) and corneal staining were measured at different follow-up visits. Data were analyzed by analysis of variance and t test for paired data. Results: Twenty pediatric patients were included in this retrospective study. MRD was severely reduced before surgery in all cases: it ranged from −1 mm to −4 mm (−2.4 ± 0.8 mm). After surgery, MRD increased to 2.9 ± 0.3 mm, and then progressively decreased by 0.6 mm within the first three months (p < 0.001); a further reduction of 0.2 mm, occurring between three and 12 months after surgery, was not statistically significant (p < 0.001). Between the 12-month and the five-year follow-up visits (one visit every six months), no changes in MRD were found for any patient. After the five-years visit, no substantial changes were recorded in 18 patients (90%); in two patients, a second surgery to improve the deterioration was necessary. Corneal staining, which was present in five patients (25%) during the first two postoperative weeks, disappeared over five years of follow-up. Conclusions: During the five-year follow-up of this retrospective study, the frontalis suspension with a silicone band proved to be a stable procedure. After 30 months from the first observation, MRD values were stable, except for two patients that underwent a second surgery to stabilize the worsening ptosis.

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.

A deadly droop: small cell lung cancer presenting as upper eyelid ptosis

Orbital metastases are a rare manifestation of systemic malignancies, most commonly originating from the breast or lung in adults. Not infrequently there is not any diagnosis of cancer at the time of presentation with orbital metastatic disease. This is a case of a 62-year-old man whose initial presentation of metastatic small cell lung cancer was left upper lid ptosis and hypoglobus.

Modified Supramid Brow Suspension in Paediatric Ptosis

Purpose: To understand the safety and complication profile of the modified supramid brow suspension surgery in the paediatric ptosis.Design: Retrospective interventional case series.Methods: Review of medical notes of 32 patients who underwent supramid brow suspension surgery of the upper lid. Surgery was performed by a single surgeon at Great Ormond Street Hospital, London during 2007–2012. Complication rates were analysed.Results: Forty-six eyes of 32 patients underwent upper eye lid brow suspension surgery; 18 cases were unilateral and 14 bilateral. Mean follow-up period is 28 months after the surgery. Post-operative granulomatous reaction was noted in 6 eyes (13%) and prolonged exposure keratopathy in 2 eyes (4.3%). There were no cases of suture infection or exposure. No recurrence of ptosis was observed in any of the operated cases. Pupillary axis clearance was achieved in all eyes.Conclusion: Modified brow suspension surgery using supramid for upper eyelid ptosis is a safe and clinically useful procedure with low complication rate.