Residual Lagophthalmos Research Articles

Modified Levator Resection Technique for Moderate Congenital Blepharoptosis.

For moderate ptosis associated with fair levator function (LF), the levator resection is the most commonly used procedure. However, the levator resection technique still has some disadvantages, such as residual lagophthalmos (RL), undercorrection, conjunctival prolapse, and eyelid contour abnormality. To solve the above problems, our team have made modifications to the levator resection technique in three aspects: releasing the levator muscle sufficiently, preserving the supporting structure of the conjunctiva, and placing multiple suture sites. Fifty-seven patients (81 eyes) underwent the modified levator resection technique and were enrolled in the study. Preoperative data collected included age, sex, margin reflex distance 1 (MRD1), and LF. Postoperative data collected included MRD1, RL, patient satisfaction, complications, and length of follow-up. Mean MRD1 significantly increased from 1.45 ± 0.65 mm preoperatively to 3.57 ± 0.51 mm postoperatively. Mean LF significantly increased from 6.49 ± 1.12 mm preoperatively to 9.48 ± 1.39 mm postoperatively. Successful correction was obtained in 77 eyes (95.1%). Mean RL was 1.09 ± 0.57 and 72 eyes (88.9%) showed excellent or good eyelid closure function. Fifty-four patients (94.7%) were completely satisfied with the final result. Complications such as hematoma, infection, conjunctival prolapse, suture exposure, corneal abrasion, and keratitis were not found in any cases during follow-up. This modified levator resection technique introduced in this study is effective in correcting moderate congenital blepharoptosis, while minimizing RL, undercorrection, conjunctival prolapse, eyelid contour abnormality by releasing the levator muscle sufficiently, preserving the supporting structure of the conjunctiva, and placing multiple suture sites. This journal requires that authors 42 assign a level of evidence to each article. For a full 43 description of these Evidence-Based Medicine ratings, 44 please refer to the Table of Contents or the online 45 Instructions to Authors www.springer.com/00266 .

"Extended Frontalis Muscle Advancement Technique for Severe Congenital Blepharoptosis".

The conventional frontalis muscle advancement technique still has some disadvantages, such as residual lagophthalmos, eyebrow ptosis, eyelid contour abnormality, and under-correction. This article describes the authors' extended frontalis muscle advancement technique that takes extensive subcutaneous separation through the eyelid crease incision for the treatment of severe congenital blepharoptosis. A retrospective review was performed that included patients with severe congenital ptosis who underwent extended frontalis muscle advancement technique from April of 2019 to April of 2021. Preoperative evaluation included age, sex, and margin reflex distance 1 (MRD1), levator function, and lagophthalmos. Postoperative evaluation including correction result, closure function of eyelid, cosmetic result was performed at the last follow-up. From April of 2019 to April of 2021, a total of 102 patients (137 eyes) who underwent extended frontalis muscle advancement technique were included in the study. The mean postoperative MRD1 in unilateral and bilateral ptosis patients was 3.84 ± 0.60 mm and 3.86 ± 0.56, respectively, and 126 eyes (92.0 percent) showed successful correction. Postoperatively, the mean residual lagophthalmos was 0.88 ± 1.40 mm, and 127 eyes (92.7 percent) showed excellent or good eyelid closure function. The average score of cosmetic results was 8.29 ± 1.34, and 94 patients (92.2 percent) had an excellent or good cosmetic result. Extensive subcutaneous separation relieves the mutual restriction between the forehead skin and frontalis muscle. The extended frontalis muscle advancement technique is effective in correcting severe congenital ptosis, while minimizing under-correction, residual lagophthalmos, eyelid contour abnormality and eyebrow ptosis. Therapeutic, IV.

Aesthetic Correction of Mild-to-Moderate Blepharoptosis Among Asians: The Bridge Technique.

IntroductionAlthough several surgical methods have been introduced to treat mild-to-moderate blepharoptosis, including levator-based techniques such as Müller muscle–conjunctival resection, few complications and better functional and aesthetic outcomes remain elusive for plastic surgeons. Hence, this study aimed to provide a new technique (bridge technique) using the levator aponeurosis–Müller’s muscle flap to achieve optimal blepharoptosis correction for function and aesthetics among Asians.MethodsFrom January 2019 to May 2020, this new technique was performed on 157 consecutive patients with mild-to-moderate blepharoptosis. Our technique was based on the anchor of the levator complex to the tarsus using mattress stitches and three-layer fixation, which provided a reliable motion transmitter for elevating the upper eyelid. The patients’ medical records and photographs were reviewed 12 months postoperatively to assess the margin reflex distance 1 (MRD1), incidence of complications, and aesthetic outcomes.ResultsThe average preoperative and postoperative MRD1 measured 1.2 ± 0.31 mm and 3.7 ± 0.34 mm, respectively. A significant difference was observed between the preoperative and postoperative distance values (p < 0.001). In the aesthetic evaluation, the grading was good, fair, and poor for 142 (90.4%) patients, 10 (6.4%) patients, and 5 (3.2%) patients, respectively. Complications included undercorrection in 12 (5.2%) cases and overcorrection in nine (3.9%) cases, and no cases of residual lagophthalmos were recorded.ConclusionMild-to-moderate blepharoptosis among Asians can be corrected effectively using this new technique. However, the long-term outcomes of this procedure should be explored.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40123-021-00417-3.

Conjoint Fascial Sheath Suspension for Correction of Recurrent Blepharoptosis.

Blepharoptosis is defined as an abnormally low-positioned upper eyelid margin in the primary gaze position, which results in cosmetic discomfort and functional visual dysfunction. Recurrence is one of the common complications after ptosis correction and requires further revision. Conjoint fascial sheath (CFS) suspension has become increasingly popular for ptosis. In this article, we described our experience of CFS suspension in the treatment of recurrent blepharoptosis and evaluated the postoperative outcomes so as to guide the clinical application of CFS suspension. Thirty-eight patients (48 eyelids) who had recurrent blepharoptosis and received CFS suspension were included in this study. Before the surgery, the degree of ptosis and levator function were assessed. The postoperative evaluation consisted of the correction effect, eyelid symmetry, protective closure function of eyelid, and surgical complications. At the final follow-up, 46 eyelids (95.8%) showed an ideal correction, of which 24 eyelids (50%) showed sufficient correction and 22 eyelids (45.8%) showed normal correction. The remaining 2 eyelids (4.2%) showed under-correction. Among all 38 patients, 26 patients (68.4%) achieved good symmetry, and 10 patients (26.3%) achieved fair symmetry, while only 2 patients (5.3%) showed poor symmetry. Recovery time of eyelid protective closure function was 3.9 ± 1.04months (range, 2.5-6months). There were no complications except residual lagophthalmos (9 eyelids) residual conjunctival prolapse (10 eyelids). CFS suspension is an effective method for the correction of recurrent blepharoptosis due to its sufficient correction effect, recovery of eyelid protective closure function, and less complication rate. 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 .

Autogenic facia lata suspension for correction of paralytic ectropion

Objective: To evaluate the outcome of autogenic facia lata suspension in the treatment of paralytic ectropion. Methods: It was a retrospective case series study. The clinical records of 21 patients (21 eyes) who were treated for paralytic ectropion with autogenic facia lata suspension between January 2015 and September 2017 at Beijing Tongren Hospital were analyzed. In the 21 patients, 7 were male and 14 were female. The range of age was 20-74 years and the mean age was (61±14) years. All of the participants received facia lata suspension for the correction of ectropion. Some of the patients also received associated wedge resection of the tarsus or lateral tarsal strip procedure. The anterior lamella was reconstructed with local flaps in some patients. The preoperative and postoperative degree of ectropion was measured. Paired sample t test was used to compare the preoperative and postoperative data. Results: Postoperative follow up for patient was conducted for 6-38 months. Residual lagophthalmos of 3 mm or more were present in 3 cases. Mild lower eyelid ectropion recurred in 1 patient one year after surgery. The rest cases achieved satisfactory aesthetic outcomes. No complication in the donor site was observed. The preoperative scleral show was (3.02±1.31) mm, and the postoperative data was (-0.05±0.72) mm. The preoperative margin reflex distance 2(MRD2) was (8.83±1.77) mm, and the postoperative MRD2 was (5.43±0.78) mm. The preoperative lagophthalmos was (6.17±1.91) mm, and the postoperative data was (1.98±1.09) mm. The differences between the preoperative and postoperative data were significant (t=13.530, P=0.000;t=11.913, P=0.000; t=11.882, P=0.000). Conclusion: Autogenic facia lata suspension is an effective method for the correction of paralytic ectropion, with good aesthetic outcome, low recurrence rate and few complications. (Chin J Ophthalmol, 2018, 54: 496-501).

Комбинированный способ хирургического лечения при паралитическом лагофтальме с применением имплантатов из политетрафторэтилена

The purpose is to develop a combined method of paralytic lagophthalmos treatment using polytetrafluoroethylene (PTFE) implants. Material and methods. The clinical group consisted of 20 patients (8 males, 12 females) aged 31-69 (44.7 ± 5.3 years) with facial nerve paralysis, who were treated within the last 3 years. The onset of paralytic lagophthalmos took place 1-9 years (3.3 ± 2.1 years) before surgical treatment. A typical clinical picture was as follows: lagophthalmos 9-16 mm (13.3 ± 3.1 mm), retraction of the upper eyelid 3-6 mm (4.1 ± 1.1 mm), atony and ectropion of the lower eyelid, epitheliopathy (11 cases), leucoma (9 cases). Visual acuity was 0.01-1.0 (0.3 ± 0.15). All patients had surgery for lagophthalmos with the use of a PTFE implant. In 5 patients, surgery was performed in two stages (separately for the upper and the lower eyelids), in 15 cases it was performed simultaneously, using a combined method The implant was a porous PTFE tape 200-300 μm thick, either solid or with perforations. The follow-up period was 6 months to 3 years (1.9 ± 0.9 years). Results. No complications have been revealed either in the early or late follow-up periods. All patients had positive dynamics of the following parameters: the size of lagophthalmos, the presence of ectropion of the lower eyelid, retraction of the upper eyelid, the condition of the cornea. The evaluation was conducted 6 months after surgery or later. In all cases, lagophthalmos decreased significantly, the residual lagophthalmos was 2-5 mm (3.1 ± 1.3 mm). The condition of the cornea in patients with keratopathy improved, vision increased to reach 0.1 1.0 (0.5 ± 0.25). Conclusion. In the proposed method, the lagophthalmos is eliminated by lower eyelid strengthening and upper eyelid recession. PTFE implants provide a stable effect. For citation: Filatova I.A., Shemetov S.A. Combined method of surgical treatment for paralytic lagophthalmos with polytetrafluoroethylene (PTFE) implants. Russian ophthalmological journal. 2018; 11 (2): 27-34. doi: 10.21516/2072-0076-2018-11-2-27-34 (In Russian).

Correction of lower eyelid retraction with hard palate graft in the anophthalmic socket

ObjectiveLower eyelid retraction is a common and challenging complication of the anophthalmic socket. The underlying pathophysiology includes contraction of the posterior lamellae of the eyelid, shortening of the inferior fornix, and lateral canthal tendon laxity. This study aimed to evaluate the surgical efficacy of hard palate mucosa as a posterior spacer graft in the lower eyelid retraction repair in the anophthalmic socket. MethodsThe surgical technique involved hard palate grafting combined with recession of inferior retractors and lateral tarsal strip suspension to lengthen the posterior lamellar and strengthen the support of the lower eyelid. The records of anophthalmic patients with lower eyelid retraction who underwent this technique from January 2009 through August 2014 were reviewed. Postoperative outcomes were determined by lower eyelid elevation, presence of lagophthalmos, complications, prosthesis fitting, and patient satisfaction. ResultsA total of 12 patients (12 eyelids) were included. The mean age at surgery was 36 years (range, 29–52 years) and the mean follow-up period was 53 months (range, 20–71 months). The lower eyelids of the operated eyes significantly elevated by 2.9 ± 0.8 mm, and mild residual lagophthalmos was observed in 3 patients. All patients were satisfied with the surgical outcomes. Minor complications occurred in 3 cases, including mild recurrent retraction, granuloma, and mucous discharge. There were no complications detected at the donor site. ConclusionHard palate grafting combined with recession of lower eyelid retractors achieves long-term stable outcomes in lower eyelid retraction repair in the anophthalmic socket.

A modified implant for upper eyelid ptosis correction in frontalis suspension surgery

to develop a modified implant to correct ptosis through brow suspension and to evaluate its effectiveness. The clinical group consisted of 20 patients (29 eyes) aged 23 to 69 years (45±5.3 years on the average) and the comparison group - of 20 patients (33 eyes) aged 19 to 77 years (47±9.5 years on the average). All patients were operated on for severe ptosis of the upper eyelid, which implied stitching their eyelids to the eyebrows. In the main group, an original implant was introduced as suspensory material - a 200 µm thick porous polytetrafluoroethylene tape, length 13 cm, width 6 mm, round staggered perforation pattern, 1.5 mm holes, 3.5 mm pitch. In the comparison group, Mersilene mesh strips were used. The article contains a detailed description of the surgical technique. Checkups were performed at 1, 6, and 12 months. Follow-up periods were up to 4 years (1.7 years on the average) in the main group and up to 7 years (5.1 years on the average) - in the controls. Were evaluated by the width of the palpebral fissure at raised eyebrows, marginal reflex distance (MRD, which is the distance between the center of the pupil and the upper eyelid margin), presence and depth of the upper eyelid crease, and residual lagophthalmos. Examinations held at months 1, 6, and 12 after surgery showed that the results were positive and stable in all cases. Neither signs of recurrence, nor statistically significant differences between the groups were found. The use of the original modified implant during frontalis suspension surgery provides high and stable cosmetic result and expands the possibilities of ophthalmic plastic surgery.

Levator lengthening technique using cartilage or fascia graft for paralytic lagophthalmos in facial paralysis

Lid loading using gold weights has been commonly used to treat paralytic lagophthalmos (PL); however, the procedure has a relatively high complication rate and the availability of these plates varies among social circumstances. We used a levator lengthening (LL) technique, which originally elongated the levator aponeurosis by inserting a fascia graft between the edge of the levator aponeurosis and the tarsal plate. However, because this procedure tends to result in a wide residual lagophthalmos, we changed the graft material from fascia to conchal cartilage. In this study, we describe in detail our experience with LL using the cartilage graft. LL was performed in 18 patients with PL. Fascia grafts were used in seven patients and cartilage grafts in 11. Static reconstructions of the lower eyelid and eyebrow were also performed in most patients. Efficacy was evaluated from patient reports of ocular symptoms and by measuring the palpebral fissure width at opening and closing for both eyes. All patients experienced improved ophthalmological symptoms, which were more apparent in cartilage cases. The average palpebral fissure at eyelid closure was 1.8mm in cartilage cases and 4.0mm in fascia cases. In cases where an eyebrow lift was concurrently performed, the residual lagophthalmos became wider in fascia grafting but remained acceptable in cartilage grafting. LL is a simple and useful procedure for treating PL with higher efficacy when a cartilage graft is used. However, the level of the upper eyelid can be easily adjusted by changing the fixation position of the cartilage. Additional experience is required to obtain more consistent outcomes.

Repeat Posterior Lamellar Grafting for Recalcitrant Lower Eyelid Retraction Is Effective

Purpose: To review one surgeon’s (J.H.O.) experience with repeat retractor release and posterior lamellar grafting in patients with residual lower eyelid retraction. To quantify the amount of eyelid elevation expected from each procedure.Method: Retrospective chart review of patients with repeat posterior lamellar grafting between 1992 and 2010. Patients were grouped into thyroid associated orbitopathy (TAO) and other causes. Hard palate mucosa or free tarsoconjunctiva grafts were used. Preoperative and postoperative inferior scleral show, lagophthalmos, superficial punctate keratopathy, and patient symptoms were recorded. Outcome measures were changes in scleral show and lagophthalmos with each procedure. Combined results were examined.Results in patients with TAO were analysed separately and compared with other etiologies.Results: In this series, a single procedure is expected to reduce scleral show by a mean of 1.63 mm (76%) and lagophthalmos by a mean of 0.48 mm (55%). A second procedure can further reduce residual scleral show by a mean of 0.71 mm (80%) and residual lagophthalmos by a mean of 0.43 mm (76%). Patients with TAO were more likely to have larger measurements of preoperative scleral show (1.40 mm versus 0.46 mm, p < 0.001). Patients with other etiologies were more likely to have larger measurements of preoperative lagophthalmos (1.25 mm versus 0.47 mm, p = 0.004).Conclusions:This is the first study to evaluate outcomes of recalcitrant lower lid retraction requiring repeat posterior lamellar grafting. Mean reductions in scleral show and lagophthalmos can be used as a guide in the preoperative evaluation and counseling of patients with lower lid retraction.

Gold weight implants in the management of paralytic lagophthalmos

Lagophthalmos secondary to facial nerve damage can lead to corneal exposure and eventually blindness. Appropriate management depends on the severity and likely duration of recovery. Upper eyelid gold implants play an important role in the medium and long term management of this condition. The authors report their experience with 16 consecutive patients who underwent gold weight implantation of the upper eyelids for correction of paralytic lagophthalmos and describe their surgical technique. The mean age of the patients was 70 years with a male predominance (M:F=3.2:1). Radical parotidectomy (69%) was the most common reason for the intervention. The mean weight of the implant was 0.95 g. There were no intraoperative or immediate postoperative complications. One implant (6%) was extruded and one patient (6%) had residual lagophthalmos and required a heavier implant. 15 of the 16 patients were satisfied with the outcome and all had adequate lid closure at last follow up.

Complications of gold weight eyelid implants for treatment of fifth and seventh nerve paralysis.

Complications occurred in six patients after gold weights were implanted into the upper eyelid tissues for fifth and seventh nerve palsies. These complications included implant infection without extrusion (in one patient); entropion with trichiasis and presumed inflammatory reaction to the gold weight material (in one patient); upper eyelid distortion and poor eyelid contour with corneal ulceration and scarring (in one patient); significant residual lagophthalmos with exposure keratitis (in one patient); and blepharoptosis obscuring the pupillary access (in two patients). Resolution of the complications required 1. implant removal in four of six patients without reinsertion of a second weight, 2. recession of the retractors of the upper eyelids with medial and lateral canthoplasty (in four patients), and 3. permanent tarsorrhaphy (in one patient). The authors conclude that complications may be minimized by careful preoperative determination of the optimum implant size, weight, and placement within the eyelid as well as meticulous attention to the surgical technique of implantation. The use of other eyelid protective procedures is often necessary to augment corneal protection especially in patients with combined fifth and seventh cranial nerve palsies. Endogenous implant infection without extrusion of the gold weight may be distinguished from presumed inflammation due to gold allergy by clinical response to antibiotics in the former and requirements of steroids or removal of the implant in the latter.