Surgical treatment of blepharoptosis (literature review)

Blepharoptosis is currently a serious pathology, the treatment of which does not always bring a satisfactory result. The article provides a review of the literature, describes the methods of surgical treatment of this ophthalmopathology. Each method is distinguished by indications, outcomes, efficiency. The method of surgical intervention depends on the cause of ptosis, the function of the levator muscle, the patient's age, visual acuity and a number of other indicators, but the main criteria are the degree of preservation of the levator function and lowering of the upper eyelid. The classic algorithm for treating patients with blepharoptosis involves shortening the levator or suspending the muscle that raises the upper eyelid to the eyebrow. Key words: ptosis of the upper eyelid, resection of the levator, function of the levator, operations of suspending type.

Modified Levator Muscle Complex Suspension on Treating Pediatric Blepharoptosis with Poor Bell’s Phenomenon

Purpose: To evaluate the surgical outcomes of pediatric congenital blepharoptosis with poor Bell’s phenomenon (BP) treated with modified levator muscle complex suspension.Methods: Forty-two pediatric congenital blepharoptosis patients with poor BP were treated with modified levator muscle complex suspension, and their major surgical outcomes such as marginal reflex distance1 (MRD1), palpebral fissure height (PFH), and postoperative lagophthalmos were retrospectively reviewed. Results: The mean follow-up was 10.28±9.89 months (range: 3-32 Months). Surgical success was achieved in 54 (87.1%) of 62 eyelids at the final visit, including excellent results in 46 (74.2%) eyelids, good results in 8 (12.9%) eyelids, and poor results in 8 (12.9%) eyelids, respectively. The postoperative PFH of affected eyes (7.97±1.47 mm) was significantly improved compared with that before surgery (3.58±1.31 mm). The mean MRD1 was improved from -1.48±1.36 mm before surgery to 2.94±1.46 mm after surgery. The postoperative MRD1 was ≥ 3 mm in 46 eyelids and < 3 mm in 16 eyelids. The mean lagophthalmos was 1.42±1.20 mm 3 months after surgery. All of the patients presented complete blink postoperatively. Postoperative complications were rarely observed during follow-up. No patient had exposure keratitis, but blepharoptosis recurred in 6 patients (8 eyelids). All patients had satisfactory eyelid symmetry and contour. No complications were observed until the last visit.Conclusions: The modified method results complete blink, mild and quick recovery of lagophthalmos, flexible eyelid motility, stable ocular surface, and it is simple to perform with few complications and a low recurrence rate at 12.9%, which is worth to wide application on poor bell’s phenomenon blepharoptosis.

High Eyelid Crease Deformity in Asians: A Clinical Evaluation and Corrective Strategies

The aim of this study was to describe the manifestations of post-blepharoplasty high eyelid crease patients and to propose steps of clinical evaluation and corrective operations. High eyelid crease patients were categorized into 3 groups, including pre-existing ptosis (PP), surgical induced levator compromised (SI), and high eyelid crease alone (HC), based on their MRD1 and signs of compromised levator muscle. The primary outcomes were the type and success rate of the operative techniques. The secondary outcomes were the complications. A total of 131 patients were enrolled, 7 males and 124 females, with an average age of 39.7 years. The mean scar height in the HC, SI, and PP groups were 10.4 ± 2.2, 12.8 ± 2.6, and 9.0 ± 2.0 mm, respectively. The scar height in the SI group was statistically differently higher than the other groups (mean: 1.7 mm, 95% CI: [0.91, 2.43]; P < 0.001). In total, 117 eyes of 67 patients underwent corrective operations with significant lower eyelid fold height and an 83.6% success rate. There were 6 re-operation eyes, 5 in the SI group and 1 in the PP group. High blepharoplasty incision scar can lead to surgical induced levator compromise and ptosis. Systematical evaluation and optimal corrective operations are needed to achieve targeted outcome.

A Newly Modified Technique for Levator Muscle Tucking in Blepharoptosis Surgery: An Egyptian Tertiary Center Study

Background: To highlight a newly modified technique for levator muscle tucking for the management of mild to moderate blepharoptosis.Methods: A prospective single-centre study enrolling 180 patients with blepharoptosis at Ain Shams University Hospitals from March 2017 to February 2019. Patients of unilateral or bilateral mild to moderate ptosis with good levator function (more than 8 mm) were included. Those with severe, traumatic, recurrent, mechanical ptosis, Marcus–Gunn jaw winking syndrome, third nerve palsy, absent Bell’s phenomenon, or abnormal ocular motility were excluded. The follow-up was at one week, one month, three months, six months, and one year visits. Functional outcome was assessed by analysis of the upper eyelid margin position in relation to the superior limbus and classified as very good (2 mm), good (2–4 mm), poor (5 mm) and preoperative to postoperative difference in marginal reflex distance (MRD). The aesthetic outcome was assessed in the form of symmetry of eyelid height, lid contour, lid crease presence, and degree of patient`s postoperative satisfaction.Results: The newly modified technique of levator tucking had a success rate of 92.1% in the form of a very good (77.7%) and good (14.4%) functional outcome, with highly acceptable aesthetic outcomes: symmetry of eyelid height in unilateral cases (86.1%) and bilateral cases eye (84%), lid contour regularity (91.6%) and lid crease symmetry (88.8%). Postoperative patient satisfaction was 83%, with a short operating time of 27.4 ± 4.6 minutes per eye.Conclusion: The newly modified technique of levator tucking is a rapid, simple, highly effective technique, with less recurrence and high patient satisfaction.Trial Registration:· Trial registry: ClinicalTrials.gov· Unique identifying number: NCT04883853· Date of registration: 11/5/2021 (retrospectively registered).

Histopathological Evaluation of A Tissue Fragment Obtained In Conjunctivo-Müllerectomy Surgery

Purpose To evaluate striated skeletal muscle fibers (upper eyelid levator muscle) in specimens taken from conjunctivo-müllerectomy surgery and correlate the surgical response of elevation greater than 2 mm in this surgery. Methods Histopathological analysis of 20 excised conjunctivo-müllerectomy fragments for treating involutional ptosis of any magnitude with a 10% positive and satisfactory phenylephrine test to check for skeletal muscle fibers. Results All analyzed tissue samples only had conjunctiva and smooth muscle tissue. We attest to the absence of striated muscle fibers in these samples. Conclusion There are no upper eyelid levator muscle fibers in the excised tissue in conjunctivo-müllerectomy surgery. The surgical response of elevation greater than 2 mm in this surgery may only be due to the closeness of the upper eyelid levator muscle to the superior border of the tarsal plate.

Predicting the Success Rate of Levator Resection Surgery Using Whitnall Ligament Position

Ptosis is defined as lower positioning of the upper eyelid margin which normally is placed 1.5 mm below the superior corneal limbus [1]. Ptosis can be accounted as the 3rd most common eyelid disorders following chalazion and entropion [2]. It may result in amblyopia, visual field defect, cosmetic and psychological problems. Generally, ptosis is subdivided to congenital and acquired cases [3]. Abnormal development of levator muscle or innervation abnormalities is responsible for congenital cases of ptosis. On the other side, trauma, several neurologic disease, and defective levator aponeurosis can lead to acquired ptosis [4]. Levator function, clinical feature, and concomitant eyelid or face abnormalities are the determining factors for choosing appropriate surgical plan [5]. Common surgical approaches include frontalis suspension technique and levator muscle procedures (levator advancement and levator resection) in which frontalis suspension is performed in cases with poor levator function and the latter one is suitable for patients with preserved levator function [4]. Levator resection outcomes are not absolutely predictable. Multiple factors such as ptosis severity, levator function, and age of patient have been discussed as predictive factors for surgical success rate.

Influence of Various Factors on Results on Phenylephrine Test

Phenylephrine test is one of the main factors determining the possibility of performing superior tarsal muscle resection. However, the influence of various factors on its result remains unexplored.Aim. To evaluate the effect of patient age, degree of ptosis, and levator muscle function on the result of the phenylephrine test.Patients and methods. 45 patients were examined (64 eyelids). The following examinations were performed for all patients: assessment of the degree of ptosis, levator muscle function and the phenylephrine test.Results. Age and the degree of ptosis do not affect the results of the phenylephrine test. Reduced levator muscle function leads to a decrease of the phenylephrine test results.Conclusion. The phenylephrine test remains an important criteria for patient selection for the planning superior tarsal muscle resection. Levator muscle function does affect the phenylephrine test result.

Evaluation of the Symmetry of the Levator Veli Palatini Muscle and Velopharyngeal Closure Among a Noncleft Adult Population

Purpose: The goal of this study is to determine the typical range of asymmetry between the length and thickness of the levator veli palatini muscle and to explore the impact of the observed asymmetry on velopharyngeal closure. A second objective is to report normative length and thickness of the levator veli palatini muscle among adults with typical velopharyngeal anatomy. Method: Magnetic resonance imaging (MRI) data and Amira 5.5 Visualization software were used to evaluate the levator veli palatini muscle among 89 participants with typical velopharyngeal anatomy. Flexible nasopharyngoscopy was used to determine the function of velopharyngeal closure among 39 of the 89 participants with typical velopharyngeal anatomy to examine the functional impact of observed asymmetry. Results: Matched paired t tests demonstrated a nonsignificant difference between the length and thickness of the right and left levator muscle. The mean difference between the right and left length of the levator muscle was 2.28 mm but ranged from 0.09 mm to 10.37 mm. In all cases where individuals displayed asymmetry in the levator muscle through MRI, there was no observed impact on the symmetry of velopharyngeal closure. Discussion: This study suggest that differences in the right and left levator veli palatini muscle are not significant among individuals without cleft palate. However, among individual cases where asymmetry was sizeable, there was no direct impact on the closure pattern. This may suggest there are multiple factors that contribute to asymmetrical velopharyngeal closure that are beyond the level of the levator veli palatini muscle.