Severe Blepharoptosis Research Articles

Combination of Dermal fat Grafting and Frontalis Suspension Using Polytetrafluoroethylene Sheet for Blepharoptosis With a Deep Sulcus.

The frontalis suspension procedure is a common surgical method for patients with severe blepharoptosis. While frontalis suspension is a very effective method, the transplant material may be visualized after surgery in patients with a deep sulcus and severe blepharoptosis. To prevent this complication, we performed a combination of dermal fat grafting and frontalis suspension using a polytetrafluoroethylene sheet in 5 patients (6 eyelids). We followed-up the patients for at least 6 months postoperatively (mean: 6.8 months) and observed no transplant material visualization or occurrence of infection. The mean pre- and postoperative margin reflex distance-1 was -3.75 (-5 to -2) and 2.10 (1-3), respectively. Bulky upper eyelids were observed 6 months postoperatively in 1 patient (2 eyelids). None of the patients underwent reoperation. In conclusion, the combination of frontalis suspension using a polytetrafluoroethylene sheet and dermal fat grafting for severe blepharoptosis and a deep upper eyelid sulcus was effective in preventing visualization of the transplant material.

Use of an Orbital Septum Flap for Correcting Severe Blepharoptosis.

Several surgical procedures are available for the treatment of severe blepharoptosis with poor levator function. However, the procedures have advantages and disadvantages. Particularly, complications such as lagophthalmos and lid lag are commonly observed after conventional interventions. Thus, the present study aimed to introduce a surgical technique that uses an orbital septum flap without the orbital oculi muscle for the correction of severe blepharoptosis. The technique utilizes the orbital septum flap, which is connected with the frontalis muscle via the galea aponeurosis and frontal periosteum, to suspend the tarsal plate. In this case series, the technique was used for the correction of blepharoptosis in 16 eyes from 12 patients. The margin reflex distance in all patients improved at 6 months after surgery. Two patients presented with lagophthalmos and three with mild recurrence. However, revision surgery was not required, and none of patients presented with lid lag. For the correction of blepharoptosis, the use of the orbital septum flap without the orbital oculi muscle can be easily selected compared with other conventional methods that are more likely to cause overcorrection and closure disorders. 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 .

The Function-Preserving Frontalis Orbicularis Oculi Muscle Flap for the Correction of Severe Blepharoptosis With Poor Levator Function.

BackgroundSevere blepharoptosis with poor levator function (LF) has traditionally been managed with exogenous frontalis suspension but complications such as lagophthalmos, infection, and rejection are often reported.ObjectivesThe aim of this study was to design a function-preserving frontalis orbicularis oculi muscle (FOOM) flap to correct severe blepharoptosis with poor LF. The long-term surgical outcome of the technique was assessed.MethodsThis retrospective study included only adult patients with severe blepharoptosis and poor LF, all of whom had their surgery performed by the senior surgeon over a 6-year period. Clinical assessment of LF, palpebral fissure height (PFH), marginal reflex distance 1 (MRD1), duration of follow-up, and postoperative complications were recorded.ResultsA total of 34 patients and 59 eyelids were recorded during a mean follow-up period of 17.7 months. Postoperative evaluation yielded mean [standard deviation] improvements of PFH gain of 5.62 [1.61] mm (P < 0.001), and MRD1 and PFH increases of 4.03 [0.82] mm (P < 0.001) and 8.94 [0.81] mm (P < 0.001), respectively. All patients demonstrated normalization of orbicularis function: no lagophthalmos was observed at the 8-month postoperative follow-up. Recurrence of ptosis was recorded in 4 eyelids (6.78%). Revisions were performed in 2 eyelids (3.39%). No infection or granuloma was noted.ConclusionsThe function-preserving FOOM flap is a useful vector for frontalis suspension. Not only does it effectively address lagophthalmos as well as other complications, but it provides aesthetically pleasing outcomes in patients with severe blepharoptosis and poor LF.Level of Evidence: 4

Comparing the outcome of Muller's muscle conjunctival resection for mild/moderate versus severe involutional aponeurotic ptosis.

To compare predictability of the outcomes of Muller's muscle conjunctiva resection (MMCR) in patients with severe versus mild/moderate involutional aponeurotic ptosis. This was a retrospective case-control study. All cases were recruited into the groups in terms of preoperative marginal reflex distance of upper eyelid (MRD-1). Group 1 consisted of patients with mild to moderate blepharoptosis was defined as an MRD-1 equal to 1.1 to 3 mm and Group 2 consisted of patients with severe blepharoptosis defined as MRD-1 ⩽ 1 mm. All patients underwent MMCR based on the response to phenylephrine and the amount of ptosis. MRD-1 obtained both manually and with ImageJ analysis program preoperatively and on the postoperative sixth month was compared. Successful surgical outcome criteria were defined as MRD-1 ⩾ 2.5 mm and inter-eyelid symmetry ⩽ 1 mm. A total of 97 eyes of 83 participants met the inclusion criteria for this study (Group 1 n = 50, Group 2 n = 47). In terms of MRD-1 success rates were 88% in Group 1, and 70.2% in Group 2 (p = 0.03). Preoperative MRD-1 which was measured by ImageJ, and the amount of resected tissue in mm were the predictive data of surgical outcome by the logistic regression analysis (OR 6.45, 95% CI 1.82-22.78, p = 0.004, OR 2.47, 95% CI 1.05-5.80, p = 0.037, respectively). The surgical success of MMCR can be predicted via tissue resection length and preoperative MRD-1. Higher surgical success rates were obtained in cases with mild-moderate ptosis and clinically acceptable success rates were obtained in cases with severe ptosis.

Factors Affecting the Outcome of Frontalis Sling Surgery in Patients with Severe Blepharoptosis

Background:Several factors play a role in the outcome of severe blepharoptosis correction by frontalis sling surgery, including the age of a patient, sex, causes of ptosis, and its severity, among others. Identifying the factors that most severely affect surgical outcomes could reduce the complication rate and improve patients’ satisfaction.Methods:This was a retrospective analytical study using logistic regression statistics to evaluate the effects of the following 6 factors on frontalis sling surgical outcomes: age, sex, cause of ptosis, type of anesthesia used, eye side (right or left), degree of ptosis, and levator function. These factors were compared with 10 types of surgical outcomes. The study included 120 eyelids in 95 patients, of which 70 eyelids were unilateral and 50 eyelids were bilateral. Patient ages ranged between 2 and 75; patient sex distribution was 47.5% females and 52.5% males.Results:The study yielded 60 comparison tables. Only statistically significant and clinically relevant data are presented and discussed. Overall, male patients showed better eye symmetry (P < 0.026) and better satisfaction (P < 0.004) than did females. Causes other than the congenital ptosis are characterized by better eye closure during sleep (P = 0), in comparison with congenital ptosis cases.Conclusion:The use of silk suture as a sling material is recommended for male patients, as its use produces better results, including eye symmetry and patient satisfaction, with a lower complication rate compared with that in female patients.

Conjoint fascial sheath suspension for early correction of severe blepharoptosis after double-eyelid blepharoplasty.

We aimed to investigate the feasibility and efficacy of early correction of severe blepharoptosis after double-eyelid blepharoplasty using conjoint fascial sheath (CFS) suspension. From July 2013 to July 2016, 23 patients (25 eyes) with severe blepharoptosis were treated with CFS suspension and followed up for 12-36 months. The levator function, margin reflex distance, patients' satisfaction with the appearance of the double eyelids, and complications were retrospectively analysed. Full correction was achieved in 24 eyes and overcorrection in one eye. No undercorrection was noticed. Postoperatively the mean levator function was significantly increased (from 1.5 to 10.2mm) and the margin reflex distance was significantly increased from -1.0 to 4.8mm. All patients were satisfied with the appearance of the double eyelids. No recurrence of blepharoptosis occurred postoperatively. One patient had postoperative chemosis and was well-managed with conservative treatments. CFS suspension is a safe and effective way to treat severe blepharoptosis after double-eyelid blepharoplasty. The treatment is effective in the long term.

Blepharoptosis among Korean adults: age-related prevalence and threshold age for evaluation

BackgroundTo evaluate the prevalence of blepharoptosis among Korean adults and the characteristics of blepharoptosis patients, and to determine an appropriate age threshold for recommending blepharoptosis evaluation.MethodsThe Korean National Health and Nutrition Examination Survey (KNHANES-V) was conducted in 2010–2012. We extracted data on 17,878 Korean adults aged more than and equal to 19 years included in KNHANES-V, and determined blepharoptosis prevalence according to age, to determine the cutoff age for recommending blepharoptosis evaluation. We also determined the possible association between blepharoptosis and obesity parameters, such as body mass index (BMI) and waist circumference (WC).ResultsThere was astrong association between older age and the prevalence of blepharoptosis. The cutoff age for recommending blepharoptosis evaluation was 63 years for males, 70 years for females, and 66 years for all patients. Patients with a high BMI and large WC had a higher prevalence of blepharoptosis in all age groups except for those aged over 80 years. The association of blepharoptosis with BMI according to age group showed that in the 50–59 and 60–69 years age groups, blepharoptosis prevalence and BMI were higher. However, in the 70–79 and 80–89 years age groups, extremely obese patients (BMI > 30) showed a decreased blepharoptosis prevalence.ConclusionsModerate to severe blepharoptosis can result in poor visual function and exacerbate headaches and depression, leading to decreased quality of life. This study proposed an appropriate age threshold for recommending evaluation of patients with blepharoptosis among the general population of Korea.

Evaluation of All Causes of Visual Function Loss in Children With Congenital Blepharoptosis.

To evaluate the overall frequency of visual function loss in pediatric patients with congenital blepharoptosis. This retrospective study was conducted in a tertiary center. The clinical records of patients younger than 18 years who were diagnosed as having congenital blephroptosis, underwent surgery, and had at least 1 year of postoperative follow-up were evaluated. Visual acuity results, presence of structural eye abnormalities, presence and type of amblyopia and strabismus, and refractive errors were recorded. The Mann-Whitney U test, chi-square test, and stepwise regression analysis were used for statistical analyses. The mean final visual acuity was 0.11 ± 0.23 logarithm of the minimum angle of resolution (logMAR) (range: 0.0 to 1.0 logMAR) at the final follow-up visit for 143 eyes of 123 patients (65 male and 58 female). In this cohort, 30 patients (24.4%) had amblyopia and 5 patients (4.1%) had visual loss related to structural eye pathology, amounting to a total of 35 patients (28.5%) with visual function loss. The mean final visual acuities of patients without amblyopia, patients with amblyopia, and patients with organic eye disorders were 0.01 ± 0.03, 0.29 ± 0.28, and 0.55 ± 0.42 logMAR, respectively. Severe blepharoptosis (≥ 4 mm) was present in 25 patients (83.3%) with amblyopia. Deprivational amblyopia was detected in 25 of 36 eyes (69.4%) with amblyopia. Independent risk factors associated with final visual acuity were presence of amblyopia at presentation (correlation coefficient [ß] ± standard error [SE] = -0.29 ± 0.04; P < .001), anisometropia (ß ± SE = -0.27 ± 0.06; P < .001), and ptosis severity (ß ± SE = -0.09 ± 0.04; P = .012). Visual impairment (visual acuity < 20/40) persisted in 11.9% of eyes at the final follow-up. Visual function loss was present in one-third of pediatric patients with congenital blepharoptosis. Both amblyopia and structural eye disorders contribute to visual impairment in this patient population. Structural eye pathology contributes independently to 4.1% of visual loss in this clinical setting. [J Pediatr Ophthalmol Strabismus. 2020;57(2):97-102.].

Mangament of Severe Congenital Blepharoptosis

Mangament of Severe Congenital Blepharoptosis

The Application of Temporal-Fasciae-Complex Sheet in Treating Severe Blepharoptosis

To introduce the application of the temporal-fasciae-complex sheet in treating severe blepharoptosis by frontalis suspension and evaluate its postoperative effect. Between 2008 and 2016, 25 patients (33 eyelids) underwent this procedure. A 3-cm incision in the temporal region was made to harvest a sheet of deep temporal fascia with the loose aponeurosis attached on both sides. The sheet was then grafted through a preseptal tunnel to perform the suspension. The margin reflex distance 1 after suspension (MRD1S), the margin reflex distance 1 as lifting eyebrow forcefully (MRD1F), the eyelid excursion and the closableeyelidfunction were used to evaluate the postoperative effect. A total of 22 patients (30 eyelids) completed the study with a mean follow-up period of 23 ± 8.78months. There was a statistically significant difference between the MRD1 and MRD1S (p < 0.05), the preoperative and postoperative MRD1F (p < 0.05), the preoperative and postoperative eyelid excursion (p < 0.05). All the upper palpebral margins were located above the pupils and no longer affected visual acuity in primary gaze. No severe complication andrecurrence were documented within a maximum follow-up period of 36months. Frontalis suspension with the temporal-fasciae-complex sheet is an efficient method to correct severe blepharoptosis with less complications and recurrences. The application of the sheet can not only overcome the influence of adhesion but also lift the eyelid both functionally and cosmetically. 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 .

Treatment strategy for severe blepharoptosis

ObjectiveTo establish a treatment protocol for severe blepharoptosis. This protocol helps to achieve improved accuracy and more stable correction outcome. MethodsThe levator muscle function was evaluated pre-operation. When the levator function was less than 1 mm, the frontalis suspension technique was performed; when the levator function was more than 1 mm, the techniques of levator resection, combined excision of the tarsus and levator, and tarsus–levator–CFS suspension were performed sequentially until a satisfactory correction result was achieved. ResultsA total of 389 patients with severe ptosis (561 eyes) were included; 102 eyes received levator resection, 314 eyes received combined excision of the tarsus and levator, 53 eyes received tarsus–levator–CFS suspension, and 92 eyes received frontalis suspension. In total, a satisfactory correction result was achieved in 466 eyes, while 95 cases still presented with under-correction. The symmetry findings showed that 107 (27%) cases presented good symmetry, 203 (52%) cases presented moderate symmetry, and 79 (21%) showed poor symmetry. ConclusionThis new treatment protocol overcomes the drawbacks of the traditional strategy by standardizing the correction procedure, leading to improved accuracy and more stable correction results.

Analysis of long-term outcomes after surgery in patients with severe blepharoptosis

Analysis of long-term outcomes after surgery in patients with severe blepharoptosis

Frontalis–Orbicularis Muscle Advancement for Correction of Upper Eyelid Ptosis: A Systematic Literature Review

To review the level of standardization of frontalis-orbicularis muscle advancement to correct severe blepharoptosis and the degree of scientific evidence supporting the procedure as a useful modality of blepharoptosis repair. The authors searched the Medline, Lilacs, and Scopus databases for all articles in English, Spanish, and French that used as keywords the terms "frontalis muscle flap," "orbicularis muscle flap," and "ptosis." Data retrieved included authorship specialty, geographic region where the surgeries were performed, characteristics of the samples reported, type and dimensions of the flaps used, time of follow-up, rate of undercorrection, and complications. Thirty-eight articles were retrieved and analyzed. Most studies originated from Asian countries, especially China, Taiwan, and Korea. Many variations of the procedure were encountered, including location of incisions and frontalis flap design. There were 23 case series with more than 10 patients. None compared the procedure to conventional frontalis suspension surgery. The samples were not homogeneous, including patients with different type of ptosis, variable degrees of levator function, and using distinct methods of evaluating eyelid position. Undercorrection rates ranged from 1.8% to 38% with a median value of 12.2%. The rate of complications (eyelid crease abnormalities, entropion, hematoma, and supraorbital nerve injury) was low. The direct frontalis-orbicularis muscle advancement has been judged positively in all reports analyzed. However, the level of standardization of the surgery is low, and the reported series are not homogeneous. Further studies are needed to better evaluate this operation.

Clinical efficacy of frontalis muscle flap suspension with single incision of double eyelid for the correction of severe congenital blepharoptosis in children

Objective To evaluate the efficacy of frontalis muscle flap suspension with single incision of double eyelid for the correction of severe congenital blepharoptosis in children. Methods The data of 92 eyes of 64 children with severe congenital blepharoptosis from Jan. 2007 to Jun.2017 were retrospectively analyzed. All children were treated with the frontalis muscle flap suspension with single incision of double eyelid.They were followed up 3 - 6 months. Results In the early postoperative period all children had mild lagophthalmos, and they recovered to nomal in 1 month after surgery. At the last follow-up time, all cases got a satisfied efficacy with nomal palpebral fissure height and symmetric double eyelids. Efficacy was satisfactory in 83 eyes of 57 cases (90.22%), good in 9 eyes of 7 cases(9.78%) , and no inefficient case occurred. No complication occurred such as malformed upperlid fold deformity, entropion, ectropion, formix conjunctival prolapse, exposure keratitis or infection. Conclusion The frontalis muscle flap suspension with single incision of double eyelid is a safe and effective technique for severe congenital blepharoptosis in children with small injury and less complications.It can achieve good surgical results. Key words: Blepharoptosis, congenital, severe, children; Frontal muscle flap suspension, single incision, double eyelid

The Magnetic Levator Prosthesis for Temporary Management of Severe Blepharoptosis: Initial Safety and Efficacy.

PurposeWe further optimized and evaluated the safety of the magnetic levator prosthesis (MLP) for temporary management of severe blepharoptosis, and compared efficacy and comfort against the ptosis crutch.MethodsThe interpalpebral fissure (IPF) of participants (n = 12) with ptosis was measured during attempted eyelid opening, volitional closing, and spontaneous closing with no device, ptosis crutch, or the MLP. A 10-point scale documented comfort. Additionally, a 20 minute and then 1 week trial of the MLP was offered. Safety measures were skin erythema rating, change in visual acuity, and change in corneal staining.ResultsThe MLP and crutch opened the eye (IPF 11.2 and 9.3 mm), but the MLP allowed better volitional closure (IPF 1.0 vs. 4.9 mm, P = 0.009), but was no better in allowing spontaneous blink (IPF 7.5 vs. 7.7 mm, P = 0.722). Both devices were equally comfortable (both median 8/10 comfort, P = 0.46). With extended use, opening with the MLP showed IPF 9.24 mm at 20 minutes and 9.46 mm at 1 week, and volitional closure was IPF 0.95 and 0.52 mm, respectively. Closure on spontaneous blink improved with extended wear to IPF 5.14 and 5.18 mm, respectively (P = 0.002). Two participants exhibited moderate skin erythema and one had increased corneal staining without change in acuity.ConclusionsThe MLP is safe and feasible for temporary correction of severe ptosis.Translational RelevanceFirst group data in patients showing successful reanimation of the eyelid with magnetic force.

Clinical efficacy of conjoint fascial sheath of the levator and superior rectus attached to conjunctival fornix suspension surgery in treatment of severe blepharoptosis

Objective To investigate the clinical efficacy of conjoint fascial sheath (CFS) of the levator and superior rectus attached to the conjunctival fornix suspension surgery and the modified frontails muscle suspension in the treatment of severe blepharoptosis. Methods There were 15 eyes of 11 patients in the group with CFS suspension and 12 eyes of 10 patients in the other group with frontails muscle suspension. Follow-up was conducted for 1 week to 6 months. The surgical results were compared with statistical analysis. Results Among the patients 2 cases of palpebral fissure was closed poorly, 1 cases of upper eyelid had poor shape, 4 cases of upper lid was lag, 2 cases of recurrence in group with modified frontails muscle suspension, and compared with 1 case of less straightening phenomenon in the group with CFS suspension. All the others, palpebral fissures were completely closed, the appearance of double eyelid was good, with no exposure keratitis. In terms of postoperative curative effect in 6 months observation, group with CFS suspension had less complications and was of advantages in the symmetry of upper eyelid fissure. The effect of correction post operation and upper eyelid back amount in the group with CFS suspension were better than those with the frontails muscle suspension in 6 months. There was significantly statistical difference. Conclusions The surgery with CFS suspension is of advantages of aesthetic appearance, high security, natural look, high satisfaction from patients, less complications and more in line with the physiology, which is worthy of clinical reference. Key words: Blepharoptosis; Frontails fascia flap suspension; Conjoint fascial sheath; Levator muscle

Treatment of Children With Congenital Severe Blepharoptosis by Frontalis Aponeurosis Flap Advancement Under General Anesthesia in a Single Incision

This study aimed to investigate the effect of frontalis aponeurosis flap advancement in children with congenital severe blepharoptosis. A total of 23 cases (25 eyes) of children who had congenital severe blepharoptosis and poor levator function (≤4 mm) and received frontalis aponeurosis flap advancement treatment in the Plastic Surgery Department of the Children's Hospital of Fudan University from January 1, 2013, to January 1, 2015, were retrospectively analyzed to evaluate the postoperative effects. All patients (age range, 6-27 months) were followed up for an average duration of 15.3 months. Twenty eyes (80%) had excellent effects, 2 eyes (8%) had good effects, and 3 eyes (12%) had poor effects. The average preoperative marginal reflex distance was 0.2 mm (-2 to 2 mm), and the postoperative average marginal reflex distance was 3.1 mm (1-4 mm). None of the patients showed hematoma, infection, keratohelcosis, symblepharon separation, ectropion, trichiasis, or other postoperative complications. Frontalis aponeurosis flap advancement could be used to treat congenital severe blepharoptosis with good short-term effects.

Comparison on the efficacy between combined fascial sheath suspension and frontalis muscle suspension for severe congenital blepharoptosis

Objective To compare the clinical efficacy between combined fascial sheath suspension and frontalis muscle suspension for the treatment of severe congenital blepharoptosis. Methods The data of 76 eyes of 60 cases with severe congenital blepharoptosis were collected.All cases were divided randomly into two groups.The observation group contained 39 eyes of 32 cases and control group 37 eyes of 28 cases.Observation group were treated with combined fascial sheath suspension, the control group underwent frontalis muscle suspension. The therapeutic efficacies of two groups were compared. Results In the observation group the effective rate was 92.30%, and in the control group was 89.20%. The difference between two groups was not significant(P=0.638). The rate of complication and recurrence in observation group were 10.25% and 2.78%; the control group were 35.14% and 18.18%.The difference were staristically significant(P=0.009, 0.034). Conclusion Combined fascial sheath suspension is an effective method for the treatment of severe congenital blepharoptosis. It can improve function of the upper eyelid, with little injury, less complication and low recurrence rate. Key words: Blepharoptosis, congenital, severe; Suspension surgery, combined fascial sheath, frontalis muscle

Changes of corneal tomography in patients with congenital blepharoptosis

The study aimed to evaluate the effect of drooped eyelid on corneal tomography in congenital blepharoptosis patients. Sixty-four patients with congenital blepharoptosis and 64 age- and sex- matched healthy subjects were included. According to the eyelid margin to corneal light reflex distance (MRD), eyes with congenital blepharoptosis were categorized as mild, moderate, or severe. The eyes were scanned using the rotating Scheimpflug camera. Increased topometric parameters were observed in moderate and severe blepharoptosis. Back corneal elevations at the thinnest point were significant higher for mild (P = 0.009), moderate (P < 0.001), and severe (P < 0.001) congenital blepharoptosis compared with controls. Maximum Ambrósio’s relational thickness (ART) was decreased in eyes with severe blepharoptosis (P < 0.001). Fnal D values were significantly higher in moderate (P < 0.001) and severe blepharoptosis (P < 0.001) groups than that of controls. There were significant correlations between MRD and most corneal tomographic parameters. Our findings indicated there was a trend toward subclinical keratoconus-like changes in the corneas of congenital blepharoptosis, with the increase of ptosis severity.

Combined fascial sheath suspension and levator palpebrae muscle shortening for the treatment of recurrent moderate and severe blepharoptosis

Combined fascial sheath suspension and levator palpebrae muscle shortening for the treatment of recurrent moderate and severe blepharoptosis