Traumatic Ptosis Research Articles

A Retrospective Cohort Study of the Clinical Presentation and Visual Outcomes of Blepharoptosis Treatment

Background: Blepharoptosis (ptosis) is the drooping of the upper eyelid, which can be congenital or acquired and caused by various factors. It can lead to vision impairment, such as amblyopia in children, and reduced visual fields in adults, affecting quality of life. Aim: To analyze the clinical manifestation of ptosis, specifically examining the available treatment options and evaluating the resulting visual outcomes. Methods: A comprehensive analysis was conducted on the medical records of patients diagnosed with ptosis who received treatment through both surgical and non-surgical approaches between January 2017 and December 2020. Additionally, an examination of the underlying factors contributing to the condition was performed and presented. Results: A total of 28 patients, with an average age of 31.48 ± 21.66 years, received treatment at our facilities. Out of the 26 cases of unilateral ptosis, 11 patients (43%) underwent surgery, while 15 patients (57%) were treated with medications. The majority of the surgical cases were due to congenital ptosis (8 patients), followed by traumatic ptosis (3 patients). Among the patients who did not undergo surgery, neurological ptosis was present in 6 cases, while congenital ptosis was observed in 5 cases. All cases were successfully managed, resulting in good visual acuity and no complications. Conclusion: The most prevalent type of ptosis is congenital ptosis, which primarily affects males and tends to occur more frequently in the left eye. In acquired cases, traumatic ptosis is the most commonly observed type according to this study. After undergoing surgery, patients with congenital ptosis experienced improved visual outcomes, displaying good cosmetic appearance and achieving a visual acuity of 6/6-6/18.

Recent modified technique for levator muscle tucking in blepharoptosis surgery

Purpose The aim of this study is to introduce a new modification on the classic technique of levator muscle tucking for correction of mild to moderate blepharoptosis and to evaluate its functional and aesthetic outcome. Patients and methods This is a tertiary-center study that included 180 patients with mild to moderate ptosis with good levator function (≥8 mm) according to Beard’s classification. Patients with severe congenital, recurrent, mechanical, traumatic ptosis, third nerve palsy, Marcus–Gunn jaw winking syndrome, absent Bell’s phenomenon, or associated ophthalmoplegia were excluded. A recently introduced resection tucking procedure with a spindle excision of the levator aponeurosis was performed. The procedure outcome was assessed functionally by measuring the distance between the upper lid margin and the superior limbus in bilateral cases and accordingly they were classified as very good (2 mm), good (2–4 mm), and poor (5 mm) as well as comparing the preoperative to the postoperative margin reflex distance (MRD1) in unilateral cases. Assessing the aesthetic outcome was done by measuring the eyelid height symmetry, presence of lid crease, lid contour, and patients’ postoperative satisfaction. Results The success rate of the procedure was 92.1% [very good (77.7%) and good (14.4%), P < 0.0001]. The MRD1 improved significantly from a preoperative value of 3.28±0.44 mm to 4.44±0.57 mm postoperatively (P < 0.0001). Regarding the aesthetic outcome, symmetrical lid height was achieved in 86.1% of the unilateral cases and in 84% of the bilateral cases, while symmetry of the lid crease was reported in 88.8% of the cases and regularity of the lid contour in 91.6% of the cases. Postoperative patients’ satisfaction was reported by 83% of the patients. The time of procedure was 27.4±4.6 min/eye. Conclusion This modified technique of levator tucking was performed in a short time and proved to be an effective technique, with minimal complications and high aesthetic satisfaction outcome.

SURGICAL TREATMENT OF SEVERE TRAUMATIC PTOSIS BY CONTRALATERAL FRONTAL SUSPENSION

Ptosis, a common congenital or acquired disease, is an upper palpebral droop secondary to impaired action of the levator muscle of the upper eyelid. In its severe form, he is very unresponsive or inactive. Severe traumatic ptosis is most often the result of neurogenic, myogenic or scarring lesions. The treatment of severe ptosis is essentially surgical, with a variety of techniques giving acceptable results. Frontal suspension is the therapeutic method of choice, performed according to the Fox or Crawford procedure. But it requires an active homolateral forehead muscle, capable of raising the decient eyelid; criteria that could be missing. So what would be our alternative? In our study, we report a case of severe traumatic ptosis in a young patient, associated with a palsy of the homolateral frontal muscle, treated by contralateral frontal suspension using autologous material

Reconstruction of a Traumatic Large Upper Eyelid Avulsion with Tarsoconjunctival Graft and Rotational Flap: A Surgeon’s Preference

Introduction: Large, full-thickness upper eyelid defects management presents a thorough and challenging approach due to the multilaminar character of the eyelid and its dynamic function. The Cutler-Beard flap method has been the mainstay management, but posterior lamellar graft usage with recent modifications may reduce complications. Case Presentation: A 43-year-old man presented to the emergency ward after a traffic accident left him with a full-thickness laceration on his left upper eyelid and an approximately 60% avulsion on the one-third medial of the eyelid. Traumatic ptosis was also found. After considering the large size of the affected area and the probability of faster wound healing, a free graft from the tarsus and conjunctival eyelid of his fellow eye was harvested to replace the posterior lamellar of the affected eye and closed the defect with a rotational skin flap from the remaining of the left upper eyelid. Conclusions: This technique could be one of the alternatives to the more common cutler-beard flap with mild complications. However, temporary visual obstruction cannot be avoided due to the traumatic ptosis complication of this patient.

Karakteristik Klinis Pasien Laserasi Kelopak Mata Akibat Trauma di Pusat Mata Nasional Rumah Sakit Mata Cicendo

Introduction : Trauma of eyelids due to sharp object, blunt object, road traffic accidents etc. are the major causes resulting in injuries to eyelids. A good identification and prompt treatment can improve the outcome of palpebral laceration. Purpose : To describe clinical characteristics of eyelids laceration due to trauma without involvement of lacrimal system and other orbital Methods : A retrospective descriptive cross sectional study was conducted. Data is taken from medical records of patients diagnosed as eyelid laceration from January 2016 to November 2020. Age, gender, laterality, first reference, place, onset, cause, site of trauma, depth, outcome, complication and System for Peri-Ocular Trauma (SPOT) classification was reviewed. Results : This study comprised of total 157 patients. Most of them were males 119 (75.80%) with median of age 24. The main mechanism of injury was direct trauma 88 (56.05%). The location where the injury occured was road side accidents 81 (51.59%). Superior eyelid was the most affected 96 (61.15%). Subcutaneus tissue as wound base 68 (43.31%) and affected to margin of eyelid 36 (22.92%). Hypertropic scar was the most complication found in 40 (25.47%). The most common SPOT type injury were Type IA. Conclusion : Eyelids laceration due to trauma is common in male productive age, mainly affecting superior palpebra, mostly because of road side accidents. Hypertropic scar was most complication beside traumatic ptosis, lagophthalmos and lid margin notching. The SPOT classification can simplify a recording of palpebral injuries.

Etiology and clinical characteristics of acquired ptosis

Objective: To evaluate the demographics, etiology composition, clinical characteristics and surgical outcomes of acquired ptosis patients. Methods: Retrospective case-series study. The clinical records of 176 consecutive patients (312 eyes) with acquired ptosis were reviewed from January 2009 to December 2018 in the Ophthalmology Department of Tianjin Medical University General Hospital. The demographics, etiology composition, clinical characteristics, surgical strategies and outcomes were analyzed. Results: There were 59 male (33.5%) and 117 female (66.5%) patients suffering acquired ptosis, with an average age of (64±7) years. The disease was bilateral in 136 cases and unilateral in 40 cases. There were four etiological components of acquired ptosis: 145 cases (82.4%) of aponeurotic ptosis, 17 cases (9.6%) of neurogenic ptosis, 10 cases (5.7%) of myogenic ptosis and 4 cases (2.3%) of traumatic ptosis. The clinical characteristics of acquired ptosis varied significantly depending on etiology. Ptosis surgeries were performed on 152 cases (279 eyes), and the success rate was 92.1% (140/152). Surgical procedures included levator aponeurosis surgeries on 148 cases (275 eyes), frontal muscle suspensions on 2 cases (2 eyes) and conjunctival-Müller's ectomies on 2 cases (2 eyes). Conclusions: Acquired ptosis is more likely to occur in senile and female populations with bilateral eyelids involved mostly. Aponeurotic ptosis is the predominant type of acquired ptosis. The treatment is performed according to the clear etiological diagnosis based on clinical features, and operations are efficient for most patients with acquired ptosis. (Chin J Ophthalmol, 2021, 57: 844-849).

Etiology, management of ptosis in working age group and its surgical outcome – A prospective study

To study the etiology of ptosis among 20 - 50 years of age and analyse the management and surgical outcomes of various types of ptosis using different surgical modalities. This prospective study was conducted at Tertiary Eye Care centre in Chennai from July 2018 - June 2019.It included all patients with ptosis between the age of 20 - 50 years after excluding vascular malformations and malignant tumours of the lid. Here all variables are described with frequency distribution and displayed using percentage. Incidence of congenital ptosis was 11 cases (37%), aponeurotic ptosis 8 cases (26%), myogenic ptosis 4 cases (13%), neurogenic ptosis 3 cases (10%), mechanical ptosis. 2 cases (7%), post traumatic ptosis 2 cases (7%). 70% were males and the remaining 30% were females. Among 30 cases, 23 patients had unilateral and 7 patients had bilateral ptosis. Moderate ptosis (3-4mm) (46.7%) formed a major composition of our study shortly followed by severe ptosis (43.3%). Out of 30 cases, 9 cases were managed medically (30%) and surgical intervention was required in 21 cases (70%). Out of 7 bilateral ptosis, 2 cases were managed medically and 5 cases needed surgical intervention. Complications following frontalis sling were under correction (27.3%) in 3 cases followed by mild corneal exposure keratitis (9.1%) in one patient. Complications following levator advancement were under correction in one case (12.5%) and mild lid peaking in one case (12.5%). Among 2 cases of mechanical ptosis, one was squamous papilloma and other was a large chalazion. Out of 4 myogenic cases 3 cases were due to myasthenia and the other diagnosed to have CPEO. 2 cases of traumatic ptosis were due to traumatic 3rd nerve palsy and traumatic levator dehiscence. The most common acquired ptosis was aponeurotic followed by myogenic, neurogenic, traumatic and mechanical ptosis. Frontalis sling surgery is the most common surgery done for congenital ptosis. Use of polypropylene as a suspensory material gives a good functional outcome. Aponeurotic advancement surgery is the most common surgery performed for acquired ptosis.

A case of surgically treated traumatic ptosis caused by scratching by human hand

The patient was a 49-year-old woman. She had worked at a child welfare facility where she sustained a wound to the left side of her upper eyelid after it was scratched by a child facility resident's finger. One month had passed since the injury when she visited our hospital. The initial treatment was not appropriate, and her left eyelid could not be lifted at all. A secondary surgery was performed 2 months after the injury when the scar contracture was most strong. Such corrective surgery for posttraumatic eyelid is typically scheduled after at least 6 months when the scar tissue softens from the viewpoint of wound healing. However, this case indicated the importance of determining the appropriate timing of surgery in consideration of the patient's background and the scientific basis. Reports of sharp traumatic ptosis are rare, and this is the first reported case of traumatic ptosis resulting from a scratch caused by human hand.

Traumatic Ptosis: Evaluation of Etiology, Management and Prognosis.

Introduction:To investigate whether a systematic approach to subgrouping traumatic ptosis according to etiology can allow for better tailoring of prognosis and treatment.Methods:Retrospective chart review of patients with trauma-related blepharoptosis managed by Oculoplastic surgery specialists at an academic medical center from January 1995 to November 2015. Injury mechanism, eyelid position and function, interventions, and outcomes were reviewed.Results:Of 648 patients treated for blepharoptosis, 55 (8.5%) were traumatic. Careful review revealed 4 subcategories of traumatic ptosis cases: aponeurotic (n = 16), myogenic (n = 18), neurogenic (n = 7), and mechanical (n = 14). Margin reflex distance (MRD1) at presentation was significantly worse for the myogenic subtype (-0.59 mm, SD ±2.09, P = 0.046). The aponeurotic subtype had the best average levator function at presentation (14.29 mm, SD ±2.05), while myogenic had the worst (8.41 mm, SD ±4.94) (P = 0.004). Thirty-five (63.6%) patients were managed surgically. Final MRD1 was significantly different for each subtype (P = 0.163), with aponeurotic 2.63 mm (SD ±1.01), myogenic 1.29 mm (SD ±2.24), neurogenic 1.79 mm (SD ±2.48), and mechanical 2.31 mm (SD ±1.18). There was a significant increase in MRD1 from presentation to final follow up across all groups (P < 0.05).Conclusion:Traumatic ptosis is heterogenous. Systematically evaluating traumatic ptosis cases by trauma mechanism can guide decisions about prognosis and management. Two-thirds of cases were treated surgically, with most patients responding well to conjunctiva-Müller resection or external levator advancement. While all subgroups demonstrated improvement in MRD1 at final follow up, aponeurotic cases had the best prognosis, while myogenic fared the worst and required the longest for maximal recovery.

Tarsoaponeurectomy as an alternative in difficult blepharoptosis cases.

BackgroundThe purpose of this study was to evaluate the results of tarsoaponeurectomy in patients with unsuccessful results after repetitive surgery or who developed post-traumatic blepharoptosis.MethodsThe files of 107 patients (136 eyes) on whom surgery was performed between January 2010 and December 2014 due to blepharoptosis were scanned retrospectively. Among these patients, the files and operational notes of eight patients who underwent surgery through the method of tarsoaponeurectomy were examined in detail. The epidemiological data, indication for surgery, previous ptosis and/or eyelid surgeries and trauma histories, preoperative and postoperative measurement data (palpebral space (PS), margin reflex distance (MRD1, MRD2), levator muscle function (LMF)) of the patients were recorded. The follow-up time of the patients was 7 to 34 months with an average of 16 months.ResultsA total of eight patients consisting of three females and five males were included in the study. The age range was 19 to 63 years with an average of 39 ± 16.2 years. Four patients had traumatic ptosis history whereas four patients had previous multiple levator procedure surgery history. Those patients with a history of ptosis had undergone surgery with levator procedure at least two times. Additionally, one patient had upper eyelid entropion, one had anophthalmic socket syndrome, and one had exposure keratopathy and traumatic dilated pupil. Seven patients had ptosis in the left eye whereas one patient had ptosis in the right eye. All patients were given a tarsoaponeurectomy as the basic surgical procedure while the patient with entropion was given a tarsal fracture and ear cartilage grafting as additional surgery. Two patients with vertical notching were also given a vertical blepharotomy through which a strip of tarsus was removed.ConclusionsTarsoaponeurectomy is an alternative method for oculoplastic surgeons used to deal with patients on whom sufficient and desired results have not been achieved despite repetitive surgery and in post-traumatic cases where levator muscle and aponeurosis cannot be dissociated peroperatively.

Long-term outcomes of laser assisted blepharoplasty for ptosis: About 104 procedures in 52 patients

Background: Eyelid ptosis or blepharoptosis is defined as an abnormal drooping of the upper eyelid when looking straight ahead. Laser-assisted blepharoplasty (LAB), first introduced by Baker in 1984, presents the following advantages: improved intraoperative haemostasis, decreased operating time and improved appearance in the immediate postoperative periods. This article reports our long-term experience with LAB in ptosis correction surgery and underlines the advantages of the technique. Methods: A total of 52 patients were treated for ptosis with LAB between 2000 and 2011. The patients had an average age of 59.5 ± 9.6 years. Etiologies were senile ptosis in 34 cases, traumatic ptosis in 9 cases and congenital ptosis in 9 cases. The ptosis was classified as mild in 24 cases, moderate in 11 cases, and severe in 17 cases. The surgical technique was similar to the one described by Baker. The laser used in our studies was the CO2 Lumenis Active™ with the following parameters for skin incision: ultrapulse mode, continuous emission, 3-W power (program 1). The laser was then reprogrammed (program 2) with the following parameters for resection of a skin-orbicular muscle flap: regular mode, continuous emission, 9-W power with the beam slightly defocused. Results: Early complications included oedema in 8 patients. More than 1 mm of lid asymmetry was seen in 8 patients with 6 patients under corrected and two over corrected. Two of them chose secondary surgery. Mean down time was 5.5 ± 1.7 days (2–7 days). The mean late follow-up was performed after 2–10 years (mean 6.6 ± 1.7 years). Late complications included 4 recurrences 5, 6, 6, and 8 years, respectively, after the first procedure. All but one were successfully re-operated with the same technique. Overall patient satisfaction ranked high and all but one would recommend this treatment to others. Conclusion: LAB in ptosis surgery is a safe and reproducible technique particularly appreciated by patients. The procedure allows for improved intraoperative haemostasis, decreased operating time and improved appearance in the immediate postoperative periods.

An frontalis sling operation using an autogenous en-bloc, fan-shaped tensor fascia lata graft for blepharoptosis

This article presents a modification of the frontalis sling operation for severe blepharoptosis with poor levator function. The fascia or other suspension materials are usually used in strip form to avoid a mass under the skin and lid-crease obliteration in the frontal sling operations. However, the 'strip-sling technique' carries the risk of some complications including irregular eyelid contour, unstable fixation and loss of elevating power in the follow-up period. To overcome these complications and to enhance elevating power transmission between the tars and the frontal muscle, the autogenous tensor fascia lata graft was designed to be en bloc and fan-shaped. This technique was used in nine patients (12 eyelids) who presented with different aetiologies. They had an average follow-up of 13.5 months. Although all the patients achieved favourable results with good eyelid opening, the patients who had traumatic ptosis were more prone to complications including lagophtalmos and pulling away problem. This modification appears to increase the surface contact area between the frontalis muscle, the fascia lata graft and the tarsus. This increased contact enhances tarsus elevation in ptotic eyelids and is associated with satisfactory results.

Ptosis Correction: A Challenge Following Complex Orbital Injuries

Ptosis occurs when the muscles that raise the upper eyelid (levator and Muller's muscle) get damaged. There are lot of ptosis correction surgery reported in the journals of oculoplastic surgery and opthalmic surgery. Most of these surgeries are cosmetic correction. Rarely ptosis can be seen as a complication following orbitozygomatic complex injuries. Cause of traumatic ptosis most often is levator detachment from the superior tarsal plate. Lacerations of the lid may sever the levator tendon leading to scarring and secondary mechanical ptosis. Challenge in surgical management lies in identification of Levator aponeurosis, posterior to orbital septum and preaponeuratic fat. Once the levator muscle is freed from scar tissue it should be reapproximated to tarsal plate.

Traumatic Ptosis and Mydriasis Masking Horner Syndrome From an Internal Carotid Pseudoaneurysm

A 46-year-old woman presented after blunt facial trauma for evaluation of bilateral orbital floor fractures, which were confirmed by clinical and radiographic examination. In addition, findings of right traumatic mydriasis and left traumatic ptosis were seen. On close investigation, miosis was noted on the side of the traumatic ptosis. Therefore, a workup for Horner syndrome was obtained, including neuro-ophthalmic consultation and magnetic resonance angiography of the neck. The magnetic resonance angiography showed an internal carotid pseudoaneurysm, an uncommon but potentially fatal complication of blunt carotid injury. The authors describe an interesting case where a life-threatening diagnosis was nearly masked by more common, benign pathology.

Modified Frontalis Suspension Technique With Review of Large Series

To describe and report results of a modified frontalis suspension technique utilizing direct fixation to tarsus, lash margin rotation, eyelid crease fixation, conservative blepharoplasty, and rhomboidal configuration. A retrospective chart review of frontalis suspension patients over a 28-year period was performed. Data from 171 eyelids in 93 patients were reviewed. Ages ranged from 1 to 84 years with a median age of 16. The indications for surgery included the following: congenital ptosis in 107 eyelids (62.6%), chronic progressive external ophthalmoplegia in 17 (9.9%), jaw winking ptosis in 14 (8.2%), blepharophimosis in 12 (7.0%), cranial nerve III palsy in 10 (5.8%), traumatic ptosis in 9 (5.3%), and myasthenia in 2 (1.2%). Autogenous fascia lata was utilized in 156 lids (91.3%), while silicone rods or banked fascia was used in 11 (6.4%) and 4 (2.3%) lids, respectively.Average follow up was 11.7 months (range 2 to 108 months). An excellent result was defined as ≤1 mm asymmetry in primary gaze and an eyelid position of 2.5 mm or less below the superior limbus. Eighty-nine of 93 patients (95.7%) achieved excellent results. Six lids in 4 patients (3.5%) were undercorrected. No patients were overcorrected. Only 2 patients with autogenous fascia lata (3.4%) required a secondary bilateral frontalis suspension at the 2- and 3-year time intervals. The authors believe that technique modifications including direct eyelid crease incision and tarsal fixation, conservative fat removal blepharoplasty even in children, lash margin rotation, and rhomboidal configuration with single midline brow incision give improved results of frontalis suspension when compared with conventional techniques.

Evaluation of Transconjunctival Frontalis Suspension Using Nonabsorbable Suture

To evaluate the transconjunctival frontalis suspension technique using nonabsorbable suture (4/0 polypropylene) in patients with severe blepharoptosis and poor levator function. A total of 22 patients (33 ptotic eyelids) were included in a prospective interventional case series study. All had severe ptosis with poor levator function. Transconjunctival frontalis suspension using 4/0 polypropylene suture was done in all patients. Twelve patients (17 eyelids) had congenital ptosis, 6 patients (12 eyelids) had blepharophimosis, and 4 patients (4 eyelids) had traumatic ptosis. The surgical technique was easy and fast and surgical results in the 3 groups were good functionally and cosmetically. Recurrences in 3 eyelids (9%) happened after 3 years. Follow-up ranged from 1 to 4 years. Transconjunctival frontalis suspension technique is simple and time saving for treatment of severe ptosis with poor levator function. It gives good functional and cosmetic results. Healing was normal with no postoperative swelling or infection. 4/0 Polypropylene exhibits satisfactory results and easy manipulation.

Correction of Congenital Ptosis by Suspension of the Frontalis Muscle Flap Overlapped with the Inferior-Based Orbital Septum Flap

Congenital ptosis of the upper eyelid presents a challenging and complex medical problem in ocular plastic surgery. The type of procedure selected to correct congenital ptosis usually is determined by the amount of ptosis and the functional integrity of the levator muscle. Many patients, both pediatric and adult, with congenital ptosis will have depressed or poor levator muscle function. This presents inherent difficulty for the reliability and efficacy of standard procedures such as levator resection or muellerectomy. Left untreated, this condition can result in amblyopia (due to astigmatism or occlusion) and cosmetic concerns. The standard procedure for congenital ptosis with poor levator muscle function involves using frontalis suspension techniques to recruit frontalis muscle and surrounding tissues to aid in elevation of the eyelid. This procedure, although often successful, has many significant side effects or complications. These include morbidity of the donor site, use of foreign materials in suspension of the lid, lagophthalmos and less than natural appearance, and movement of the eyelid. This article represents a straightforward and local approach to this complex and difficult problem. The surgical approach used has the benefit of modifying an already well-established surgical procedure (frontalis suspension) while using the frontalis muscle itself and the orbital septum to provide elevation to the eyelid. The technique is totally local in nature and avoids the associated morbidity of second-site surgery to obtain donor tissue. The surgical technique also uses the patient’s own tissues and avoids problems associated with foreign bodies and grafted materials. Incorporating a blepharoplasty into the surgery improved the cosmetic effect. The article describes in detail the technical steps involved in the procedure and incorporates drawings to facilitate understanding of the technique. A good series of preand postoperative photos demonstrating results and improved cosmetic appearance are provided. The photos demonstrate good postoperative lid positions without the eyebrow strained into severe elevation. The connection of the frontalis flap and the orbital septum/levator can be adjusted to set the lid at the best possible position. Very few if any complications occurred, and the procedure seems to be generally safe and predictable. No patients experienced postoperative problems with keratitis or corneal exposure. It is important in the preoperative evaluation to assess the patient for tear production via a Schirmer’s test and for a Bell’s response. It is prudent to discuss with the patient preoperatively the possibility of corneal exposure/dry eye and to treat it as indicated. This series, although not a large, demonstrated good longevity of results and easy management of all complications. The problem of reduced eyelid excursion in up/ down gaze would be expected due to the fibrotic nature of the levator muscle in congenital ptosis. Further study of this disorder would involve use of the described procedure for pediatric patients because the most common age at pediatric repair is about 5 to 6 years. I believe this technique would be helpful for other ‘‘poor levator muscle function’’ types of ptosis including Marcus Gunn jaw winking syndrome, chronic progressive external ophthalmoplegia, double elevator palsy, and traumatic ptosis. M. N. Longo (&) Ophthalmic Plastic Surgeons of Texas, 7500 San Felipe #200, Houston, TX 77063, USA e-mail: mlongomd@pleasingtotheeye.com

Sudoriferous cyst of the orbit of adult origin after trauma

A rare case of sudoriferous cyst of the orbit occurring in an adult, who had facial trauma, is reported. Several factors suggest its adult onset. The only other case reported in an adult is of presumed childhood origin. Very few congenital cases have been reported. A 65-year-old lady presented with recent onset of left-sided ptosis and a painless mass below the left supraorbital margin. The patient had traumatic ptosis after a road traffic accident 13 years ago. The ptosis was surgically repaired, which resulted in symmetrical palpebral apertures. Computed tomographic scan revealed a well-defined cystic mass in the anterior orbit. The mass was removed in toto by anterior orbitotomy. Histopathological examination revealed a single cyst lined by double-layered cuboidal epithelium in some areas and transitional epithelium at others. A periodic acid Schiff (PAS) positive, diastase-resistant glycocalyx lined the inner epithelium. Apical snouting suggested an apocrine nature. This confirmed a diagnosis of sudoriferous cyst.

Electron microscopic findings in levator muscle biopsies of patients with isolated congenital or acquired ptosis

Systemic mitochondriopathies as chronic progressive external ophthalmoplegia (CPEO) are frequently associated with ptosis. We investigated whether mitochondrial abnormalities in the levator muscle are also found in patients with isolated congenital or acquired ptosis showing no other signs of mitochondrial cytopathy. Biopsies of levator muscle were taken during surgery from 24 patients with isolated congenital (group 1) or early-onset acquired ptosis (group 2). All patients were given a thorough clinical examination before and after surgery. Ultrathin muscle sections were examined by transmission electron microscopy. The findings were compared with biopsies from five patients with CPEO (positive control) and two patients with traumatic ptosis or pseudoptosis (negative control). The mean levator function equalled 7.3 mm (range 4-10 mm) in group 1 and 12.8 mm (range 9-15 mm) in group 2. Eight out of 11 patients in group 1 and eight out of 13 patients in group 2 were found to have mitochondrial alterations such as megamitochondria, mitochondrial matrix alterations and abnormal cristae, similar to CPEO. Within group 1 and 2, no significant clinical differences were found between patients with and without mitochondrial abnormalities. Mitochondrial alterations were found in a surprisingly large proportion of levator biopsies from patients with isolated congenital or early-onset acquired ptosis. There was no statistically significant correlation between mitochondrial alterations and levator function. Our findings suggest that the ultrastructural assessment of mitochondria in the eyelid muscle is a valuable tool, and may guide further biochemical and mutation screening tests that will help to understand the etiopathology of this disease.

A simplified technique of ptosis repair using a single adjustable suture

Purpose To describe a simplified technique for ptosis repair using a single adjustable suture. Design Retrospective noncomparative series. Participants Fifty-one cases of ptosis repair performed or supervised by the same surgeon between 1993 and 1995. Intervention The surgical approach consisted of using a single adjustable “hang-back” 5–0 silk suture for plication of the superior portion of the levator aponeurosis. Lid height was then reassessed within the first 4 postoperative days and permanently readjusted by fixating the adjustable suture. Excluded were patients with history of unstable ptosis as a result of systemic disease or congenital, mechanical, and traumatic ptosis resulting from a mass or trauma. The follow-up period ranged from 3 to 31 months. Main outcome measure Lid position. Results All eyelids included in this study were corrected to 1 mm of the desired result. There were no incidents of peaking or recurrence on long-term follow-up. Complications included one case of hematoma and a case of slight tenting of the eyelid margin. Conclusions This procedure combines the physiologic approach of levator aponeurosis surgery with the simplicity and flexibility of a single adjustable “hang-back” type suture. It may readily be combined with other procedures such as blepharoplasty. It is also useful when the “ideal” lid level may not be determined until the postoperative period, such as eyes subject to ptosis by Hering’s law, levator dehiscence, or those at increased potential risk for corneal exposure.