The clinical analysis of conjoint fascial sheath suspension on the treatment of pediatric congenital moderate-severe ptosis / 中华整形外科杂志

Objective@#To investigate the functional and cosmetic outcomes of conjoint fascial sheath(CFS) suspension surgery in pediatric congenital ptosis.@*Methods@#Forty-four moderate to severe ptosis patients(58 eyes) underwent CFS suspension surgery from December 2013 ot December 2014. With 12 to 36 months follow-up, the levator function, margin reflx distance, curve of upper eyelid, appearance and complications were recorded and analyzed, to evaluate the effect based on functionality, aesthetics and complication.@*Results@#①Functional assessment: in the 58 eyes of 44 cases, the satisfactory rate was 91.4%(53 eyes), 2 eyes(3.45%)were under—corrected, 3 eyes(5.17%) were over corrected. The mean preoperatively LF was 2.5 mm, which was increased postoperatively to 6.1 mm at the final visit.The average marginal reflex distance (MRD) was 0.1 mm preoperatively. After at least one year, average MRD was 3.8 mm (P<0.05). ②Cosmetic satisfaction assessment: According to satisfaction surveys, the rate of excellence and good was 88.64%, 6.81% fair, and 4.54% poor. ③Complications: the most common complication was reoperation, which was performed in 2 eyelids (3.45 %) because of incomplete correction and 3 eyes(5.17%) over corrected. Only one case of cornea exposure which recovered after conservative treatment.@*Conclusions@#CFS suspension was an effective treatment for moderate-severe congenital ptosis, showing good long term result.

The utility of margin‑reflex distance in determining the type of surgical intervention for congenital blepharoptosis.

Aims: To evaluate the utility of margin‑reflex distance (MRD) as an alternative to levator function (LF) in choosing the appropriate surgical procedure for congenital blepharoptosis. Settings and Design: This was a retrospective, observational study. Subjects and Methods: Records of patients with simple (dystrophic) congenital ptosis who were operated and followed for ≥6 months postoperatively and whose outcomes were deemed as successful were evaluated in the study. Success was defined as a MRD at the last postoperative visit of ≥3 mm. In all cases, levator resection was performed when LF was >4 mm and frontalis suspension when LF was ≤4 mm. Statistical Analysis Used: For statistical evaluations, LF was accepted as the gold standard parameter for deciding on the surgical intervention, and the optimum cutoff point for initial MRD was determined as the point at which sensitivity and specificity was highest at the receiving operating curve for the selection of surgical procedure. Results: Of one hundred and three eyes of ninety patients (44 female/46 male), levator resection was used in 44.7% and frontalis suspension in 55.3%. When the optimum cutoff point for MRD was determined as 0.5 mm, the sensitivity was 71%, specificity was 86%, and the area under the curve that represented the discriminative power of this parameter was found to be 0.826. Conclusion: The MRD at the cutoff point of 0.5 mm may be used as an alternative to LF to determine the type of surgical intervention in patients with congenital blepharoptosis whose LF cannot be reliably obtained in clinical evaluations.

Outcomes of Levator Resection at Tertiary Eye Care Center in Iran: A 10-Year Experience

PURPOSE: To assess outcomes of levator resection for the surgical correction of congenital and acquired upper lid ptosis in patients with fair to good levator function and evaluation of the relationship between demographic data and success of this operation. METHODS: In a retrospective study, medical records of patients with blepharoptosis who had undergone levator resection over a 10-year period and were followed for at least 3 months were reviewed. RESULTS: Overall, 136 patients including 60 (44.1%) male and 76 (55.9%) female subjects with a mean age of 20 +/- 13.8 years (range, 2 to 80 years) were evaluated, of whom 120 cases (88.2%) had congenital ptosis and the rest had acquired ptosis. The overall success rate after the first operation was 78.7%. The most common complication after the first operation was undercorrection in 26 cases (19.1%), which was more prevalent among young patients (p = 0.06). Lid fissure and margin reflex distance (MRD1) also increased after levator resection (p < 0.001). Age, sex, type of ptosis, amblyopia, levator function, MRD1, lid fissure and spherical equivalent were not predictive of surgical outcomes of levator resection. CONCLUSIONS: Levator resection has a high rate of success and few complications in the surgical treatment of congenital and acquired upper lid ptosis with fair to good levator function. Reoperation can be effective in most cases in which levator resection has been performed.

The Objective Change of the Eyelid after Upper Blepharoplasty

PURPOSE: To evaluate the morphological changes in the external eyes after upper blepharoplasty. METHODS: Twenty-six eyes of 13 patients undergoing upper blepharoplasty from May 2002 to May 2003 were selected. All surgeries were performed by one surgeon. MRD1, MRD2, interpalpebral fissure height, and levator function test were each measured twice, and the averages were calculated. Likewise, significant changes were checked before and after the operation. The subjects were divided into two groups. For group A (n=12), a double line suture was stitched at the levator aponeurosis, which was directly superior to the tarsal plate. In group B (n=14) the suture was stitched at a levator aponeurosis 3 mm superior to tarsal plate. The delta levator function (postoperative mean levator function minus preoperative mean levator function) measurements were calculated and compared between the two groups. RESULTS: The MRD1 was 2.04+/-0.75 (mean+/-SD) before the operation, and 2.0+/-0.81 after the operation. MRD2 was 5.23+/-0.75 before the operation, 5.35+/-0.54 after operation. Interpalpebral fissure height was 7.27+/-0.38 before the operation and 7.35+/-0.63 after the operation. There were no statistically significant factors before and after the operation in MRD1, MRD2 and interpalpebral fissure height. The levator function was 14.04+/-1.80 before versus 16.19+/-1.58 after. This increase was statistically significant (p<0.01, Wilcoxon signed ranks test). The delta levator function was 1.58+/-0.90 for group A and 1.96+/-1.36 for group B. CONCLUSIONS: After upper blepharoplasty, the measurement of levator function increased significantly.

Changes in Postoperative Fissure Height after Frontalis Suspension Using Autogenous Fascia Lata

PURPOSE: Most surgeries to correct congenital ptosis in children are performed with the patient under general anesthesia, which makes the postoperative outcome unpredictable. We analyzed the factors influencing postoperative changes in the fissure height of congenital ptosis patients with poor levator function under general anesthesia after frontalis suspension surgery. METHODS: We reviewed the medical charts of 79 congenital ptosis patients with poor levator function (4 mm or less) who underwent frontalis suspension with autogenous fascia lata under general anesthesia between January 2001 and December 2004. We considered lagophthalmos induced by general anesthesia as the baseline lid level, and the lid was elevated in proportion to the amount of ptosis, as assessed by photographic analysis. Photographs were taken and then analyzed using the Scion Map analysis program to measure the fissure height objectively at 1 week, 1 month, and 3 months. RESULTS: The fissure height formed by frontalis suspension surgery increased progressively and stabilized 1 month after the operation. Levator function had no significant effect on postoperative changes in fissure height. However, a more severe preoperative ptosis and a higher lagophthalmos were associated with a relatively smaller increase in adjusted lid height during the follow-up period. CONCLUSIONS: A good postoperative outcome was achieved by adjusting the lid height to a higher level in eyes with higher lagophthalmos. Especially when confronted with the dilemma of how to correct asymmetric ptosis, higher elevation of lid height in eyes with more severe preoperative ptosis and higher lagophthalmos while under (general) anesthesia should be helpful in the prediction of postoperative surgical outcomes.

Changes in Postoperative Fissure Height after Frontalis Suspension Using Autogenous Fascia Lata

PURPOSE: Most surgeries to correct congenital ptosis in children are performed with the patient under general anesthesia, which makes the postoperative outcome unpredictable. We analyzed the factors influencing postoperative changes in the fissure height of congenital ptosis patients with poor levator function under general anesthesia after frontalis suspension surgery. METHODS: We reviewed the medical charts of 79 congenital ptosis patients with poor levator function (4 mm or less) who underwent frontalis suspension with autogenous fascia lata under general anesthesia between January 2001 and December 2004. We considered lagophthalmos induced by general anesthesia as the baseline lid level, and the lid was elevated in proportion to the amount of ptosis, as assessed by photographic analysis. Photographs were taken and then analyzed using the Scion Map analysis program to measure the fissure height objectively at 1 week, 1 month, and 3 months. RESULTS: The fissure height formed by frontalis suspension surgery increased progressively and stabilized 1 month after the operation. Levator function had no significant effect on postoperative changes in fissure height. However, a more severe preoperative ptosis and a higher lagophthalmos were associated with a relatively smaller increase in adjusted lid height during the follow-up period. CONCLUSIONS: A good postoperative outcome was achieved by adjusting the lid height to a higher level in eyes with higher lagophthalmos. Especially when confronted with the dilemma of how to correct asymmetric ptosis, higher elevation of lid height in eyes with more severe preoperative ptosis and higher lagophthalmos while under (general) anesthesia should be helpful in the prediction of postoperative surgical outcomes.

The Frequency and Aspects of Ptosis in Korean Old Age

PURPOSE: To study the frequency and aspects of ptosis in Koreans aged 50 years or older. METHODS: In this study, 377 elderly people visiting retirement center were included. Margin-reflex distance 1 (MRD1) and palpebral fissure (PF) were evaluated with an attempt to eliminate eyebrow elevation. Levator function (LF) was measured with Berke's method. If the measured MRD1 was less than 2 mm, ptosis was diagnosed and its frequency, relation to sex, age, levator function and superior deep sulcus were investigated. RESULTS: There was a correlation between decreasing MRD1, PF and LF with increasing age. Ptosis was observed in 207 subjects (54.9%), and its frequency was augmented as age increased. Although it was not statistically significant, the levator function of those with ptosis (10.0+/-1.9 mm) was lower than those without ptosis (11.3+/-1.9 mm). Questionnaires were administered and 196 respondents (51%) said that their eyelid droop had become more pronounced over time. Among these respondents, 33 (16.1%) indicated that their droopy eyelid causes discomfort by blocking their vision. Their MRD1 was 1.2+/-1.0 mm, which was significantly lower than that of the other 163 respondents (1.8+/-1.1 mm, P<0.05). CONCLUSIONS: Koreans aged 50 years or older showed a very high frequency (54.9%) of ptosis and as age increased, the frequency of ptosis also increased. Surgical correction is recommended when the ptosis causes patient discomfort due to impaired vision.

The Frequency and Aspects of Ptosis in Korean Old Age

PURPOSE: To study the frequency and aspects of ptosis in Koreans aged 50 years or older. METHODS: In this study, 377 elderly people visiting retirement center were included. Margin-reflex distance 1 (MRD1) and palpebral fissure (PF) were evaluated with an attempt to eliminate eyebrow elevation. Levator function (LF) was measured with Berke's method. If the measured MRD1 was less than 2 mm, ptosis was diagnosed and its frequency, relation to sex, age, levator function and superior deep sulcus were investigated. RESULTS: There was a correlation between decreasing MRD1, PF and LF with increasing age. Ptosis was observed in 207 subjects (54.9%), and its frequency was augmented as age increased. Although it was not statistically significant, the levator function of those with ptosis (10.0+/-1.9 mm) was lower than those without ptosis (11.3+/-1.9 mm). Questionnaires were administered and 196 respondents (51%) said that their eyelid droop had become more pronounced over time. Among these respondents, 33 (16.1%) indicated that their droopy eyelid causes discomfort by blocking their vision. Their MRD1 was 1.2+/-1.0 mm, which was significantly lower than that of the other 163 respondents (1.8+/-1.1 mm, P<0.05). CONCLUSIONS: Koreans aged 50 years or older showed a very high frequency (54.9%) of ptosis and as age increased, the frequency of ptosis also increased. Surgical correction is recommended when the ptosis causes patient discomfort due to impaired vision.

A Proposal of Digital Photo-Biometry of MRD1 and New Levator Function Test

PURPOSE: The history of biometry dates back to ancient Greek. The ideal body ratio from biometry is used as a guideline in many works of art. Biometry is also used as a medical standard to determine normal or abnormal. Since the biometry of face is so complicated, many surgeons tend to regard preoperative evaluation as a bother and substitute medical records with some photographs. We introduce a new method to measure MRD1 and levator function using digital photographs, which becomes widely used lately. METHODS: MRD1 can be measured with the primary- gaze-view photo which is magnified by PhotoshopR 7.0.1. The distance from coneal reflex of ring flash to upper eyelid margin is converted to mm-unit using the piece of ruler attached on the patient's face. Levator function can be measured with up-gaze-view photo and down-gaze-view photo which are superimposed on another. The excursion distance of upper eyelid margin (a) and the excursion distance of eyebrow (b) are measured respectively. The levator function can be assessed through subtraction of two values (a-b). This method is simple and precise and can be applied directly to patient without photos. RESULTS: Using magnified digital photos and computer, this method can reduce personal error and instrumental error. Taking some digital photos doesn't take long time, so it can reduce the effort of preoperative evaluation and discomfort of patients. CONCLUSION: Digital photo-biometry is useful for retrospective study. Especially reducing personal error, it is useful when the number of specimens is huge. New levator function test is much more useful for Asian- specific eyes than Berke's method allowing frontalis muscle compensation.

Anthropometric Analysis of Levator Muscle Function in Koreans

The measurement of levator muscle function is very important in the evaluation of blepharoptosis and in the choice of surgical method for blepharoptosis. And these functional values of levator muscles are very helpful in case of being operated on bilateral ptosis. There are two methods in measuring the levator muscle function. Most popular one is Berke's mehtod and the other one is margin limbal distance. The levator muscle function is the most important factor to determine the method of treatment of bleparoptosis. The normal values of levator muscle functions are variable according to races, sex and ages. Unfortunately, there are few articles concerning them in Korea yet. So, we have inevitably utilized the Caucasian or Japanese statistical data in blepharoptosis surgery. Authors measured the levator muscle function by Berke's method and margin limbal distance in Koreans, and statistically analyzed them in 498 individuals including 234 males and 264 females. The results were recorded as follows: 1.The mean values of levator muscle function was 11.9+/-1.6mm in males and 11.9+/-1.6mm in females by the Berke's method, and it was 6.5+/-1.0 mm in males and 6.6+/-1.0mm in females by margin limbal distance. 2.No statistical difference was in males and females, in left and right levator muscle function. 3.The levator function reached the peak level at high teenagers and twenties in a great portion. After the peak level, the changing pattern of levator function was stationary or decreasing gradually.

Morphologic Study of Upper Eyelid Contour and Functional Evaluation of Levator Palpebrae Superioris Muscle in Adult and Young People

PURPOSE & METHOD: The authors analyzed the morphology of upper eyelid of 480 normal eyes of medical college students, nurses, and officers in our hospital. RESULT: The height of eyelid fissure was 8.33 mm in right eye, 8.43 mm in left eye in men and 9.05 mm in right eye, 9.14 mm in left eye in women. Intercanthal distance was 36.96 mm in men and 36.52 mm in women. The length of palpebral fissure was 27.43 mm in right eye, 27.66 mm in left eye in men and 27.82 mm in right eye, 27.87 mm in left eye in women. The epicanthal fold was found in 15.0% of men and in 10.0% of women. Most frequent type of epicanthal fold was epicanthus tarsalis. The upper eyelid crease was found in 24.2% of total participants, and 16.7% in men and 31.7% in women. The levator function according to Berke's method was 13.46 mm in right eye, 13.43 mm in left eye in men and 13.74 mm in right eye, 13.67 mm in left eye in women. MRD1 was 2.39 mm in right eye, 2.42 mm in left eye in men and 2.70 mm in right eye, 2.65 mm in left eye in women. The MLD as similar values in the evaluation of levator function was 5.89 mm in right eye, 6.08 mm in left eye in men and 4.99 mm in right eye, 5.01 mm in left eye in women. CONCLUSION: In this study we could conclude that morphological values of eyelid and levator function were measured similarly to those in western people although values such as MRD1 was noted different. We suggest that our data were helpful to decision of the standard values of Korean adult and young people.

The effect of Frontalis suspension Ptosis repair using Fascia lata in congenital unilateral ptosis

PURPOSE: This study was undertaken to determine the amount of ptosis correction in congenital unilateral ptosis patients who had been performed frontalis suspension with autologous fascia lata under general anesthesia. METHODS: The subjects consisted of 27 patients with unilateral ptosis who had been performed frontalis suspension with autologous fascia lata under general anesthesia. At 1,4,8,and 12 weeks, the width of interpalpebral fissure was measured with videocamera. RESULTS: The mean preoperative interpalpebral fissure was 3.9+/-1.2 mm. At intraoperation, the mean interpalpebral fissure was 4.5+/-0.4 mm. The mean postoperative interpalpebral fissures were 6.8+/-0.6 mm, 7.8+/-0.8 mm, 6.8+/-0.8 mm, and 6.7+/-0.8 mm at 7+/-1, 29+/-3, 57+/-4, and 96+/-9 days. In preoperative severe ptosis group (ptosis amount 4 mm), the mean postoperative interpalpebral fissure was smaller than the other group. CONCLUSIONS: The postoperative interpalpebral fissure was stabilized after the 2-month follow-up. The results of this study suggest that the amount of ptosis correction should be modified in consultation with preoperative ptosis amount.

Surgical Results of Modified Fasanella-Servat Operation

The authors studied retrospectively on the surgical results of modified Fasanella-Servat operation for blepharoptosis. The 58 patients underwent modified Fasanella-Servat operation for blepharoptosis and were followed for at least 6 months. We obtained 74.1% primary success rate in the 58 cases of blepharoptosis. The undercorrection, the most common complication, could be correctable by any other ptosis procedures such as levator resction. However, severe complications such as overcorrection and eyelid contour abnormalities were very rare. We also obtained good surgical results even in groups of moderate degree of ptosis and fair levator function which had not been indicated for Fasanella-Servat operation in general.

Postoperative Changes of Lagophthalmos and Lid Lag following External Levator Resection

Among the postoperative complications of ptosis surgery, lagophthalmos and lid lag have been significant and untolerable problems. In this study, progressive change of lagophthalmos and lid lag following external levator resection was examined in 109 eyes of 74 patients from November 1988 through March 1996. Lagophthalmos and lid lag were measured at postoperative 1 month, 3 to 9 months and 12 to 18 months. The relations of lagophthalmos and lid lag according to preoperative MRD, levator function, resection amount of the levator muscle were analyzed. Lagophthalmos measured average 1.11mm and lid lag revealed average 4. 73mm at postoperative 11 to 84 months (mean 22.2 months). At the postoperative 1 year, lagophthalmos and lid lag were significantly decreased and decreasing amount measured 1.17mm and 0.90mm, respectively. Seventy eyes showed lagophthalmos less than 1mm at mean 13 months postoperatively. The postoperative change of lagophthalmos and lid lag had relation to the preoperative levator function.

The Effect of External Levator Resection in Blepharoptosis with Poor Levator Function

The postoperative complications of frontalis sling for severe blepharoptosis with poor levator function have included undercorrection, overcorrection, exposure keratitis due to lagophthalmos, lid lag. upper lid asymmetry etc, External levator resection with aponeurotic approach was performed for 77 blepharoptosis patients (106 eyelids) with poor levator function from October 1987 through April 1996 at the Department of Ophthalmology, Yeungnam University, College of Medicine. Unilateral blepharoptosis were 44 eyelids and bilateral cases included 62 eyelids. Levator function was measured 4nim in 23 eyelids, Slum in 22 eyelids and 0-2iBin in 61 eyelids, After the follow up periods of 12-108 months (mean 36.3 months) , satisfactory resuite have been achieved in 44 eyelids (100%) of unilateral ptosis and in 30 eyelids (90.9%) of bilateral ptosis. All eyelids with 4mm levator function was successful, 22 eyelids (86.4%) with 3mm levator function were satisfactory and 61 eyelids (95. 1%) with 0-2mm levator function revealed satisfactory result. Postoperative complications included entropion (4 cases) , undercorection (2 cases) , corneal opacity (I case) and corneal ulcer (1 case). Based on this study, external levator resection could were one of the ideal techniques for severe ptosis with poor to absent. levator function.

The Change in Palpebral Fissure Height of Bilateral Eyes after Uniateral Cataract Operation

To investigate the change in upper eyelid position after cataract operation, We studied 40 eyes of 40 patients prospectively who underwent phacoemulsification and intraocular lens implantation. Levator function and vertical palpebral lid fissure height were measured preoperatively and at postoperative day 1, 7, 28 and 56 in and the surgical and the fellow eyes. Postoperative mean vertical lid fissure height decreased compared with preoperative mean vertical lid fissure height in both eyes. The postoperative decrease in vertical lid fissure height tended to decrease with times and these trends had statistically significant correlation between both eyes. This suggests that both eyes are affected by factors unassociated with the cataract surgery and it is most apparent in the immediate postoperative period. In conclusion, we recommend not only the surgical eye but the fellow eye should be evaluated preoperatively and postoperatively to understand the eyelid position after cataract operation.

The Clinical Study of 33 Cases of Congenital Blepharoptosis

The blepharoptosis is drooping of upper eyelid in primary gaze with various causes. The most common cause of ptosis is, in known as, underdevelopment of levator muscle. We evaluated the age and sexual distribution, clinical manifestation, result of treatment and it's complication of congenital blepharoptosis. The method of surgery and amount of muscle resection was decided according to several factors that is the amount of ptosis, the preoperative levator functon, and the Margin Limbal Distance(MLD). Most of patient was second decades(48.3%). In cases of unilateral ptosis, left lid was higher incidence(60%) than right lid and 4 cases(14%) were bilateral ptosis. The amount of ptosis was between 3 and 4mm in most cases(48.5%), and over the 5mm was 12 cases(36.3%). Preoperative levator function between 4 and 7mm of the patient was in 18 cases(54.5%) and 3mm or less was 12 cases(36.3%). Between 16 and 19mm muscle resection was 10 cases(43.5%), Between 12 and 15mm resection was 7 cases(30.4%). In initially corrected visual acuity with Hans Chart. 12 cases(36%) were 0.5-1.0 and 2 cases were 0.1 or less. There is no significant visual improvement after one year surgical correcton. The most common surgical procedure was levator muscle resection(73%) through anterior skin incision and followed by frontalis suspension in 9 cases(27%). The result of operation was good for the period of six months follow-up. The most common complication was undercorrection in 2 cases of levator muscle resection and 1 case of frontalis suspension. The other complications were overcorrectopn, exposure keratitis and entropion in each case, respectively.

Clinical Examination on the Blepharoptosis and the Resection of the Levator Muscle

The resection of levator aponeurosis and its muscle through the anterior approach had been performed on 50 ptotic lids of 40 patients from April, 1985 to January, 1988. Their age ranged from 28 months to 44 years old(mean, 7.5 years old). All but one of them were congenital origin. Thirty-four per cent of eyes were associated with ocular abnormalities such as strabismus, entropion, and blepharophimosis. Three patients had inguinal hernia, tongue tie, and ventricular septal defect respectively as systemic abonrmalities. The cycloplegic refraction revealed mild hyperopia in 74%, mild myopia in 18%, and moderate or severe hyperopia in 8%. Seventy per cent of eyes had with-the-rule astigmatism, while 8% had againgt-therule astigmatism. Twenty-two per cent had no astigmatism. Amblyopia was noted in 11 patients of 31 patients in whom we could check the visual acuity. The amount of levator muscle resected, which depended on the function of levator muscle and the degree of ptosis, ranged from 15mm to 24mm (mean, 20.2mm). We also applied this procedure to the patient whose levator function was less than 2mm. Good surgical results were obtained in 45 eyes(90%). Undercorrected one eye underwent reoperation using the frontalis sling.

Aponeurotic Ptosis Surgery

Sixty-five levator aponeurotic surgeries were carried out to treat acquired and congenital blepharoptosis including those with very poor levator function. Margin reflex distance(MRD) was measured and postoperative drooping of the upperlid was observed carefully during the follow-up period of 6 months to 1 year. Most of these cases had a stationary level of MRD or less than 1 mm change of MRD but three cases resulted in more than 1.5 mm postoperative fall of the upperlid. This procedure also proved the excellent surgical efficacy in severe congenital ptosis with very poor levator function. In our experience, about 1 mm overcorrection at surgery provided a more satisfactory result.