Resolving conjunctival prolapse following severe blepharoptosis correction: A simple sutureless direct excision technique and systematic review.

BACKGROUND: Conjunctival prolapse (CP) is an uncommon but challenging condition following maximal levator resection (MLR) and other extensive periorbital procedures. MLR extending beyond the Whitnall's ligament is frequently performed to address severe blepharoptosis with poor levator function (LF). Patients with CP may encounter symptoms such as ocular discomfort, tearing, vision impairment, persistent conjunctival chemosis, lagophthalmos, or exposure keratopathy. Typically, surgical intervention becomes necessary if conservative measures prove to be ineffective; nevertheless, there is no consensus regarding the optimal treatment approach. OBJECTIVES: This study aimed to propose a simple sutureless direct excision method and explore the surgical advancements in CP correction through a systematic review. METHODS: Patients with recurrent CP after MLR who underwent sutureless direct excision of the conjunctiva using loupe magnifiers at a tertiary hospital were included in this study. The clinical evolution and surgical results were recorded. PubMed, MEDLINE, EMBASE, and Web of Science databases were queried following The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. RESULTS: The comprehensive analysis of 1858 articles identified 88 patients from 24 studies, highlighting that blepharoptosis surgery is predominantly associated with CP (36.6%). Surgically treated CP showed a higher resolution rate compared to those managed conservatively (54.8% vs. 45.2%; p = 0.034). No relapse was observed in patients treated with sutureless direct excision of CP in long-term follow-up. CONCLUSION: We proposed a simple sutureless direct excision technique that offers a straightforward and efficient approach in treating CP, which is particularly suitable for cases requiring excision lengths >16 mm during MLR. Furthermore, stitch removal can be obviated after surgery.

Marcus-Gunn jaw winking syndrome: case series study and management algorithm.

PURPOSE: To identify a rationale for treatment of patients with Marcus Gunn jaw winking syndrome (MGJWS). METHODS: Retrospective review of 38 consecutive patients with MGJWS referred to a single tertiary institution. Clinical data included visual acuity, ocular motility, side of jaw-wink, presence or absence of ptosis, levator function, clinical photographs, and management undertaken. Thirty-two patients were operated on with customized surgery by a senior surgeon (FQL). RESULTS: Cases with no ptosis or mild ptosis were managed conservatively. Levator advancement (LA) was successful in case of moderate ptosis and negligible synkynesis but resulted in a more evident synkinesis. Levator resection (LR) in patients with severe ptosis was associated with high rate of ptosis recurrence. Ptosis was adequately corrected in all patients submitted to uni- or bilateral levator excision (LE) and bilateral frontalis suspension (FS) or unilateral frontalis flap (FF). Jaw winking resolved in all patients submitted to LE but recurred in three cases at a later stage. Strabismus surgery was performed simultaneously in case of associated esotropia or hypotropia. CONCLUSIONS: Moderate ptosis can be corrected with LA, but success is not related to levator function and synkinesis becomes more evident postoperatively. In severe ptosis, LR showed unpredictable results. In case of severe ptosis and severe synkinesis, uni- or bilateral LE and bilateral FS are recommended; unilateral FF is an alternative in patients who refuse bilateral treatment, as the cosmetic outcome is usually better than after unilateral FS.

The role of Whitnall's ligament position in the success of levator resection surgery in congenital ptosis.

PURPOSE: This study aimed to investigate the role of Whitnall's ligament position in the success of levator resection surgery in congenital ptosis. METHODS: It was an interventional case series on patients with congenital ptosis who underwent levator muscle resection in Farabi Eye Hospital (2020-2022). Patients with incomplete follow-up, a history of trauma, poor Bell's phenomenon, previous ocular and lid surgeries, poor levator function (≤ 4mm), and syndromic ptosis or systemic diseases were excluded. During the surgery, several factors, including the distance between Whitnall's ligament and the upper edge of the tarsus (W-distance), the vertical length of the tarsus (T-length), and the amount of levator muscle resection (LMR), were measured. A successful outcome was defined as the inter-eye difference of margin reflex distance-1 (MRD1) ≤ 1 and post-op MRD1 ≥ 3 OR the inter-eye difference of MRD1 ≤ 0.5 with any value of post-op MRD1 in unilateral cases and Postop-MRD1 > 3 in bilateral cases during the 3-months period. RESULTS: Thirty four eyes of 34 patients were included, and 79.4% of patients achieved successful outcomes. In univariate analysis, Preop-MRD1 and Preop-LF had meaningful negative correlations with the amount of LMR to reach the successful outcome (p < 0.05), which was only meaningful for Preop-LF in multivariable analysis (p < 0.05). Noticeably, W-distance had a significant positive correlation in univariate and multivariable linear regression (p < 0.05). CONCLUSIONS: W-distance can be considered a significant new parameter other than Preop-LF influencing the amount of levator resection needed to achieve success in levator resection surgery.

Surgical Outcomes of Levator Resection in Moderate and Severe Ptosis With a Good Levator Function: A Retrospective Study.

INTRODUCTION: An abnormally drooping upper eyelid in comparison with the normal position in primary gaze refers to ptosis. Levator resection should be the procedure of choice in patients with moderate to severe ptosis and a good levator function. METHODS: In this retrospective study, we analysed the surgical outcomes after large and maximal levator resection in patients with moderate and severe ptosis with a good levator function and Bell's phenomenon. All patients had a good levator function; therefore, levator resection was the procedure of choice. We performed levator resection of 20 mm and above and the desired post-operative correction was achieved. RESULTS: One patient had microcornea, and hence, he was undercorrected and his post-operative marginal reflex distance 1 (MRD 1) was 3 mm. Two patients who had severe ptosis pre-operatively had a post-operative MRD 1 of 3 mm. Rest of the patients had a post-operative MRD 1 of 4 mm. CONCLUSION: Levator resection of 20 mm or more should be performed in patients with congenital simple ptosis with a good levator function and Bell's phenomenon to achieve a favourable post-operative outcome.

Modified Levator Resection Technique for Moderate Congenital Blepharoptosis.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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. LEVEL OF EVIDENCE IV: 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 .

Congenital ptosis repair in children: comparison of frontalis muscle suspension surgery and levator muscle surgery.

PURPOSE: Comparing the surgical and refractive outcomes of congenital ptosis repair by different surgical techniques. METHODS: This longitudinal cohort study reviewed medical records of 101 patients who underwent congenital ptosis repair, from 2006 to 2022 in a single center. Analysis was performed for demographic background, co-morbidities, pre-operative and post-operative ocular examinations and refraction, complications, reoperations, and success rates. RESULTS: Following exclusion criteria, we remained with 80 patients (103 eyes) who underwent either frontalis muscle suspension surgery (FMS) (55 eyes) or levator muscle surgery (LM) (48 eyes). Patients in the FMS group were younger (mean age of 3.1 vs. 6.0 years, p < 0.001) and had worse pre-operative ocular assessments including prevalence of visual axis involvement, chin-up head position, ptosis severity, and levator muscle function (LF) (p < 0.001). Both groups had a 25% rate of reoperation, however while in the LM group reoperation was required solely due to undercorrection, in the FMS group various indications prompted reoperation. Success rate was higher in the FMS group (87.3% vs. 60.4%, p = 0.002). While pre-operative astigmatism was higher in the LM group (p = 0.019), no significant differences were observed post-operatively. Spherical and spherical equivalent changes over time were significant only in the FMS group (p = 0.010 and p = 0.004, respectively). CONCLUSIONS: Within our cohort, a higher success rate of congenital ptosis repair was observed among patients who underwent FMS compared to LM, despite similar reoperation rates. In cases of severe ptosis and moderate LF, LM demonstrated a lower-than-anticipated success rate. Astigmatic changes following ptosis repair were not consistent in either group.

A novel technique for small-incision levator resection with a double mattress suture for ptosis correction.

PURPOSE: To introduce a novel technique for small-incision levator resection in ptosis surgery and evaluate its efficacy in a pilot study among patients affected by congenital or aponeurotic ptosis. METHODS: We prospectively enrolled congenital and aponeurotic ptosis patients if their levator function was not poor (≥5 mm) from June 2021 through October 2022. Surgical technique involved a 1-cm lid crease incision, minimal dissection, and creating a loop passing through the tarsus and levator aponeurosis. Success was defined as postoperative MRD-1 ≥3 mm and inter-eyelid MRD-1 difference ≤1 mm. Eyelid contour quality was scored excellent, good, fair, and poor according to its curvature and symmetry. RESULTS: Sixty-seven eyes (35 congenital and 32 aponeurotic) were included in the study. Mean age was 34±19 years (range, 5-79 years). Mean preoperative levator function and levator resection amount were 9.53 mm and 8.39 mm in the congenital group and 12.34 mm and 4.15 mm in the aponeurotic group, respectively. Mean pre- and postoperative MRD-1 was 1.61 mm and 3.27 mm respectively (P<0.001). The overall success rate was 82.1% (95% C.I: 71.7-89.8%); the result was failure in 12 cases, of which 11 had under-correction. Preoperative MRD-1 was correlated with a success rate (P=0.017). CONCLUSION: The described technique shows non-inferior results to the previously described surgical methods and also it shows very good lid contour outcome and minimal lag. The findings suggest that the double mattress single suture technique can be used in both congenital and aponeurotic ptosis.

Surgical outcomes of tarsofrontalis sling surgery using silicon rod versus supramaximal levator resection in unilateral congenital ptosis with poor levator function.

PURPOSE: To compare the surgical outcomes of tarsofrontalis sling surgery using silicon rod versus supramaximal levator resection in patients of unilateral congenital ptosis with poor levator function (≤ 4 mm). MATERIALS AND METHODS: This randomized control study was conducted over a period of 18 months. 44 patients were enrolled in the study group. The study population was randomly divided into two groups (22 in each group). In Group A, congenital ptosis was treated with tarsofrontalis sling surgery using silicon rod and supramaximal levator resection was done in the group B. Follow-up examination was done at postoperative day 1, one week, 1 month, 6 months and 12 months. Surgical outcome measures were change in marginal reflex distance-1 (MRD 1), vertical palpebral fissure height (VPFH) and inter-eyelid difference of margin reflex distance 1 and complications in two groups. RESULTS: The mean age of patients in group A was 7.25 ± 6.10 years ranging from 1-18 years and mean age of patients in group B was 5.64 ± 2.44 years ranging from 3 to 11 years. Good surgical outcome was obtained in 73-77% of both groups. MRD1and VPFH increased significantly after surgery from baseline in both the groups (p value < 0.001). Inter-eyelid MRD 1 difference also improved significantly in both groups following ptosis surgery. CONCLUSION: Both supramaximal levator resection and tarsofrontalis sling surgery are equally effective in cases of unilateral ptosis patients with poor levator function and should be part of the surgical armamentarium for treating congenital ptosis.

Severe unilateral congenital ptosis with poor levator function: tarsoconjunctival mullerectomy plus levator resection vs frontalis sling procedure.

AIM: To compare frontalis sling and tarsoconjunctival mullerectomy plus levator resection (TCMLR) in subjects with severe unilateral congenital ptosis with poor levator function (LF). METHODS: A prospective non-randomized non-blinded single center clinical trial. Fifty patients with severe unilateral congenital ptosis with poor LF were recruited. The frontalis sling and TCMLR were performed and the functional, cosmetic outcomes, complications, and success rate were evaluated at 1, 3, and 6mo postoperatively. The t-test, Chi-square, Fishers exact, and nonparametric Mann-Whitney tests were used by SPSS software. RESULTS: Frontalis sling and TCMLR procedures were performed on 26 and 24 patients respectively. The mean age was 10.97±10.67y. LF was significantly better in the TCMLR group at months 1, 3, and 6 (P=0.002). Lagophthalmos was more common in the TCMLR group (no significant difference). At month 3, mild punctate epithelial erosions were observed more in the frontalis sling group (P=0.002). Significant complete success rate of 1st and 6th month for the frontalis sling vs TCMLR groups were 50% vs 20.8% (P=0.02), and 38.4% vs 50% (P=0.03) respectively. CONCLUSION: Complete success rate of TCMLR is higher in long-term follow-up in contrast with the frontalis sling in the short-term. Transient complications are more detected in mid-term follow-ups in both groups.

Revision ptosis surgery for under-correction after Müller muscle conjunctival resection.

INTRODUCTION: Müller muscle conjunctival resection (MMCR) may be more likely to lead to under- rather than over-correction. The choice of revision surgery is not clearly defined. METHODS: MMCR patients were included if the post-operated eyelid(s) demonstrated margin reflex distance-1 (MRD1) less than 3.5 mm, or if MRD1 asymmetry was greater than 0.5 mm, and if they underwent subsequent revision surgery. MRD1 was the primary outcome measure and complications were secondary outcome measures. Two groups were defined: patients who underwent MMCR then repeat MMCR (M-M) and those who underwent MMCR followed by external levator resection (ELR) surgery (M-L). RESULTS: 18 eyelids (16 patients) were included, 12 in M-M and 6 in M-L. Mean (SD) preoperative MRD1 was 1.84 mm (0.97), range -0.41 to 3.39 mm. There was no difference (p = 0.70) in preoperative MRD1 between M-M and M-L. In the M-M group, mean (SD) MRD1 was 1.77 mm (1.12) preoperatively, 2.35 mm (0.66) after the first surgery, and 3.44 mm (0.31) after revision. Mean MRD1 was significantly higher after revision, compared to preoperatively (p < 0.05) and after first surgery (p < 0.05). In the M-L group (n = 6), mean (SD) MRD1 was 1.98 mm (0.90) preoperatively, 1.99 mm (0.56) after the first surgery and 3.44 mm (1.24) after revision. The difference between preoperative and post revision surgery MRD1 was significant (p < 0.05). CONCLUSIONS: For patients with insufficient elevation of MRD1 or with asymmetry after MMCR, revision by MMCR or by ELR are both reasonable options.

Factors associated with corneal astigmatism change after ptosis surgery.

AIM: To evaluate the predictive factors of postoperative corneal astigmatism change in ptosis patients who underwent ptosis surgical repair. METHODS: Patients who underwent levator resection at Oculoplastic service of the Department of Ophthalmology, Naresuan University Hospital, Thailand between September 2017 and August 2019 were retrospectively evaluated. Changes in degree and axis of corneal astigmatism after ptosis surgery were compared based on patient factors consisting of age at operation, sex, preoperative margin-reflex distance (MRD) 1, and preoperative degree and axis of corneal astigmatism. RESULTS: Forty-two eyes of 28 patients were included in the study. Wilcoxon signed ranks test showed a significant postoperative corneal astigmatism change only in a subgroup of eyes with preoperative astigmatism of ≥1.5 diopters (D; P=0.006). Furthermore, 72.2% (13/18) of the eyes with preoperative astigmatism of ≥1.5 D showed a reduction of astigmatism after eyelid surgery, with the mean astigmatic change of 0.65 D. Majority of preoperative eyes demonstrated with-the-rule astigmatism pattern (45.2%), of which 57.9% showed a reduced degree of astigmatism. CONCLUSION: In patients undergoing ptosis surgery, the data demonstrate for the first time the association between postoperative corneal astigmatism change and a preoperative corneal astigmatism of ≥1.5 D. Thus, we encourage considering severity of corneal astigmatism prior to cataract or refractive surgery planning in ptosis patients, especially with toric-intraocular lens, to avoid the possibility of calculation error.

Maximal Levator Resection Beyond Whitnall's Ligament in Severe Simple Congenital Ptosis with Poor Levator Function.

PURPOSE: To evaluate the functional and cosmetic outcomes, as well as factors that influence surgical success of maximal levator resection beyond Whitnall's ligament in patients with poor levator function (LF) and severe simple congenital ptosis. METHODS: This retrospective interventional study included patients with severe simple congenital ptosis and LF of ≤4 mm who had undergone maximal levator resection beyond Whitnall's ligament with a minimum of 12 months follow-up. Postoperative marginal reflex distance-1 (MRD1) was assessed for functional outcomes as excellent, good, fair and poor. Eyelid contour and the difference in MRD1 between eyes were assessed for symmetrical cosmetic outcomes as excellent, good and poor. Demographic data, factors influencing surgical success and postoperative complications were analyzed. RESULTS: A total of 38 ptotic eyelids in 31 patients were included. Successful surgical outcomes (at least good functional and cosmetic outcomes) were achieved in 26 patients (83.87%) with the mean MRD1 of +3.61 ± 0.27 mm and +3.51 ± 0.17 mm at 1 week and 12 months after surgery, respectively. There were no significant differences in demographic and preoperative data between the successful and unsuccessful surgical outcome groups, mean preoperative ptosis measurements were 4.19 ± 0.20 mm versus 4.72 ± 0.36 mm (p = 0.242) and mean pre-operative LF were 3.16 ± 0.15 mm versus 2.29 ± 0.61 mm (p = 0.561), respectively. The only factor that significantly influenced the surgical success rate was the length of the resected levator muscle. The mean lengths in successful and unsuccessful groups were 18.15 ± 0.44 mm and 14.29 ± 0.94 mm, respectively (p = 0.011). CONCLUSION: Maximal levator resection beyond Whitnall's ligament is an effective procedure for severe simple congenital ptosis with poor LF. Refinement of surgical techniques and careful assessment of the optimal resected length for the levator muscle grants successful surgical outcomes.

Long-term surgical outcomes of levator resection in patients with Marcus-Gunn jaw-winking ptosis.

PURPOSE: To report long-term surgical outcomes of a series of MGJWS patients with moderate ptosis who underwent levator resection. MATERIALS AND METHODS: A retrospective review of medical records of 10 MGJWS patients with moderate ptosis who underwent levator resection was performed in two major eye centers in Riyadh, Saudi Arabia from January 1987 to December 2019. Clinical features, pre-operative and post-operative data of the 10 patients were recorded. OUTCOME MEASURES: Long-term upper eyelid position. RESULTS: The mean patient age at presentation was 5.4 years. Seven patients were female and three were male. All patients had moderate ptosis with marginal reflex distance ranged from 1 to 2 mm. The mean age at surgery was 9.5 years. After initial good ptosis correction for all patients, seven of them had a recurrence of ptosis several months after levator resection. CONCLUSIONS: Levator resection in MGJWS patients with moderate ptosis and good levator function is associated with a high rate of ptosis recurrence and less predictable surgical results.

Comparison between frontalis suspension and levator resection in treatment of blepharoptosis: a meta-analysis / 中华医学美学美容杂志

Objective:To compare the postoperative efficacy and complications of frontalis suspension and levator resection in the treatment of blepharoptosis.Methods:According to the Cochrane systematic review method, we searched PubMed, Medline, Cochrane Library, Wanfang database, VIP Database, and China Knowledge Network database. The randomized and non-randomized controlled trials for comparing frontalis suspension and levator resection in the treatment of blepharoptosis were included. Revman 5.3 Meta analysis software was used.Results:A total of 13 clinical trials were involved in this study, including 1308 patients. Frontalis suspension was performed in the experimental group and levator resection was performed in the control group. The OR value of postoperative efficacy between the 2 groups was 2.91, 95% CI (1.57-5.39), P<0.01, the difference was statistically significant. Postoperative lagophthalmos after frontalis suspension was better [ MD=-1.05, 95% CI (-1.43--0.68), P<0.01], the difference was statistically significant. The OR value of undercorrection between the 2 groups was 0.24, 95% CI(0.16-0.36), P<0.01, the difference was statistically significant. Conclusions:The postoperative efficacy after frontalis suspension is higher. Postoperative complications after frontalis suspension are less.

[Comparative analysis of refractive and topographic changes after eyelid surgery]. / Vergleichende Analyse der Refraktions- und Topographieveränderungen nach lidchirurgischen Eingriffen.

BACKGROUND: There is largely a lack of clarity on the question of whether refraction or topography changes are to be expected after blepharoplasty, levator resection, or a lateral tarsal strip procedure. MATERIALS AND METHODS: Therefore, in the present study, objective refraction, anterior eye segment tomography, and visual acuity tests were carried out pre- and postoperatively in 78 patients and then analyzed. The examination was carried out preoperatively, at suture removal after 10 days, and after 3 months. RESULTS: Neither after blepharoplasty nor after a lateral tarsal strip procedure were significant changes in vision or refraction seen in the topography. In contrast, the Wilcoxon sign test 10 days after levator resection showed a significant increase in the cylinder after 10 days compared to the preoperative level (p = 0.042). However, this change was no longer detectable after 3 months. CONCLUSION: The authors postulate that extensive patient education with regard to temporary visual changes, particularly in the case of levator resections, is essential and that additional refraction and topography control can be useful postoperatively.

Maximal levator resection versus Gore-Tex® sling for congenital blepharoptosis with poor levator function.

BACKGROUND: Treating congenital blepharoptosis is often mandatory to clear the visual access and avoid amblyopia; however, when the levator function is poor, achieving a satisfactory long-term outcome is challenging. This study aimed to compare the outcomes of maximal levator resection (MLR) with those of frontalis suspension (FS) using Gore-Tex ®, in the treatment of congenital blepharoptosis with poor levator function. PATIENTS AND METHODS: The study included 102 eyelids of 66 patients of mean age 4.3 ± 1.6 standard deviation (SD) years, randomly divided into two groups (51 eyes each). Group A: FS using Gore-Tex ®, Group B: MLR. Postoperative outcomes were evaluated at 1, 6 and 12 months. Patients' ophthalmic examination including margin-reflex distance (MRD1) before and after surgery and postoperative complications were recorded. RESULTS: At the end of the follow-up, the mean MRD1 increased from 0.3 ± 0.7 SD mm in Group A, 0.4 ± 0.8 SD mm in Group B preoperatively, to 2.7 ± 0.5 SD mm and 2.9 ± 0.7 SD mm, respectively (P < 0.001 in both groups). Results of Group B were significantly higher than Group A (P = 0.047). Success was achieved in 77 eyelids (75.4%), distributed as follows: 36 eyelids (70.6%) in Group A, and 41 eyelids (80.1%) in Group B. The total recurrence rate was 6.9% (seven eyes), while other complications were recorded in 23 eyes (22.5%). CONCLUSION: MLR, compared to FS with Gore-Tex® sling, can be a more efficient surgical option to correct congenital blepharoptosis with poor levator excursion. Prominent postoperative lagophthalmos warrants close ocular surface observation in early follow-up weeks.

Blepharoptosis Repair: External Versus Posterior Approach Surgery: Why I Select One over the Other.

Ptosis surgery is performed via an anterior/external or posterior/internal approach, primarily defined by the eyelid elevator muscle surgically addressed: the levator complex anteriorly or Muller muscle posteriorly. Posterior ptosis surgery via Muller muscle conjunctival resection is an excellent first choice for cases of mild to moderate ptosis with good levator function, as it is predictable, provides a reliable cosmetic outcome, requires no patient cooperation during surgery, portends a lower rate of reoperation, and rarely leads to lagophthalmos and/or eyelid retraction postoperatively. External levator resection is preferred in patients with severe ocular surface/cicatricial conjunctival disease, shortened fornices, and lesser levator function.

Surgical management of ptosis in chronic progressive external ophthalmoplegia.

PURPOSE: To determine possible complications and efficacy of ptosis surgery in a series of chronic progressive external ophthalmoplegia (CPEO) patients with healthy tear film. METHOD: It is a prospective interventional study on 24 eyes from 12 patients with the diagnosis of CPEO and ptosis. Pre-operatively, tear breakup test (TBUT) and Schirmer test were performed to assess lacrimal function unit. Levator resection was performed for 16 eyes with levator function (LF) more than 4 mm, while eight eyes from four patients with poorer LF underwent frontalis silicone sling surgery. Main outcome measures included change in marginal-to-reflex distance (MRD1) and incidence of post-operative exposure keratopathy. RESULTS: The mean age of the patients was 45 ± 15 years. The mean of TBUT and Schirmer test were 12 ± 1.98 s and 15 ± 2.76 mm, respectively. The mean follow-up period was 34 months. Four eyes encountered mild to moderate exposure keratopathy. All cases were managed medically, with no need for surgical revision. The mean pre-operative MRD1, LF, and chin-up angle were -0.54 ± 1.03 mm, 4.21 ± 1.41 mm, and 21.6 ± 6.01 degrees, respectively. The mean post-operative MRD1, LF, and chin-up angle were 2.42 ± 0.60, 4.46 ± 1.53 mm, and 3.3 ± 1.01 degrees, respectively. At 1-year follow-up visit, improvement in MRD1 and chin-up posture was statistically significant (p-value < 0.05). CONCLUSION: Normal TBUT and Schirmer test results, prophylactic lubricating therapy, and close follow-up can be as important as Bell's phenomenon and palpebral fissure height in predicting post-operative complications.

External levator resection for involutional ptosis: is intraoperative suture adjustment necessary for good outcomes?

Purpose: To directly compare an algorithmic external levator resection technique with the choice of intraoperative adjustment to the same technique without intraoperative adjustments. Methods: A sequential controlled prospective comparative cohort study. Two cohorts were compared: a historical control adjustment, and an experimental non-adjustment group. Fourteen patients, 25 eyelids, were in the historical cohort; and 15 patients, 23 eyelids, were in the non-adjustment cohort. Primary acquired ptosis patients who met inclusion criteria were considered. All patients underwent a standardized external levator resection technique. Intraoperative adjustments were performed only in the historical cohort. Age, follow-up time, surgical time, and marginal reflex distance 1 (MRD1) were collected. Statistical analysis was performed using the Mann-Whitney U test. Statistical significance was p < 0.05. Primary and secondary outcome measures were postoperative MRD1 minus goal MRD1, and surgical time, respectively. Results: Twenty-five historical eyelids were compared with 23 non-adjusted eyelids. The average patient age was 68.4 years (range 19-84) and 59.3 years (range 24-83) for the adjusted and non-adjusted groups. Six-month postoperative (postoperative minus goal) MRD1 was -0.1 mm (95% CI -0.3-0.1) and -0.2 mm (95% -0.5-0.0) (p = 0.33), and surgical time was 13.8 min (95% CI 12.6-15.1) and 9.5 min (95% CI 9.0-10.1) (p < 0.001) for the adjusted and non-adjusted cohort, respectively. Conclusions: The external levator resection, utilizing a standardized algorithm approach, is an efficacious technique for involutional eyelid ptosis. With sound technique, this method can be performed without the need for intraoperative adjustment, thereby saving operative time and achieving similar results.