Outcomes of Maximum Levator Resection in Severe Upper Eyelid Ptosis at a Tertiary Oculoplastic Service

Purpose: To investigate the surgical outcomes of maximum Levator resection in cases of severe upper eyelid ptosis at a tertiary oculoplastic service. Study Design: Interventional case series. Place and Duration of Study: Department of Ophthalmology, Lady Reading Hospital, Medical Teaching Hospital, Peshawar January 2013 to December 2017. Methods: One hundred and twenty three eyes of 107 patients, who underwent maximum levator resection for severe congenital ptosis were included. Patients with missing or incomplete notes, patients with previous ptosis surgery and ptosis other than congenital were excluded. Maximum levator resection of the muscle above the Whitnall ligament was performed under local/general anesthesia. All patients had a minimum of 6 months and maximum of 5 years followup. The postoperative complications were recorded and followed. Post operative followup was done at day one, week one and at four weekly intervals till the end of the study. Results: Out of 123 eyes, satisfactory results (excellent or good) were obtained in 111 (90.1%) eyes. Majority of the patients (56.09%) were females. Mean Preoperative Levator function was 2.3 ± 1.1mm. Mean Preoperative MRD1 was ?0.1 ± 1.5 mm and mean postoperative MRD1 was 3.9 ± 01.0 mm. The commonest complication was over correction which occurred in 5 (4.06%) cases, under correction in 4 (3.25%), crease abnormality in 2 (1.62%) cases and entropion was seen in only one (0.81%) case. Success rate was 90.1% at 6 months to 5-years followup. Key Words: Blepharoptosis; Levator resection; Levator function.

Psychosocial and mental health disorders among a population-based, case–control cohort of patients with congenital upper eyelid ptosis

Background/AimRecent studies have demonstrated adverse psychosocial and mental health disorders among children with ocular disorders. The mental health burden of children with simple congenital ptosis, however, is unknown. The purpose of this study was to compare the psychosocial and mental health findings of children with simple congenital ptosis with controls.MethodsThe medical records of all children (<19 years) diagnosed with simple congenital ptosis from 1 January 1965 through 31 December 2004 while residing in Olmsted County, Minnesota were retrospectively reviewed for psychosocial and mental health morbidity. One-to-one randomly selected age-matched and gender-matched controls from the same population were similarly reviewed.Results81 children with ptosis were diagnosed at a mean age of 3.2 years (range, 1 month–16 years), 35 (43.2%) of whom were girls. An adverse psychosocial development was diagnosed in 41 (50.6%) patients with simple congenital ptosis monitored to a mean age of 21.4 years, compared with 26 (32.5%) controls (p=0.02). A mental illness was diagnosed in 31 (38.3%) patients with ptosis compared with 16 (20%) controls (p=0.01). Children with ptosis were 2.5 times more likely than controls to develop a mental illness and 2.1 times more likely to develop a psychosocial maladjustment. Patients with ptosis were also significantly more likely to have more mental health disorders (p=0.02) and a longer duration of psychotropic medication use (p=0.005).ConclusionsChildren diagnosed with simple congenital ptosis in this population had significantly greater psychosocial and mental health morbidity compared with controls. Children with ptosis may benefit from early psychosocial intervention.

A Comprehensive Approach to Asian Upper Eyelid Ptosis Correction: The Levator Musculo-Aponeurotic Junction Formula

Background The unique anatomy of the Asian upper eyelid requires specific adaptation to the levator advancement technique for ptosis correction to achieve predictable and reproducible outcomes. Objectives The levator musculo-aponeurotic junction was used as our key landmark. With a formula that we developed, the location of fixation relative to this landmark can be predicted preoperatively. Our clinical experience and outcomes with this technique are presented in this study. Methods Our inclusion criteria were Asian patients with mild to severe ptosis with at least fair levator function. Patients with acquired or congenital ptosis, primary and revisional cases were all included. The location for the placement of the advancement sutures was measured from the musculo-aponeurotic junction of the upper eyelid levator. This distance was determined by a formula that takes into consideration 1) the amount of elevation of the upper eyelid margin needed, 2) the degree of compensatory brow elevation that is present and 3) eye dominance. Results One hundred and fifty-six Asian patients were included in this prospective study. Of these 148 were bilateral and 8 were unilateral corrections. The technique was predictable with resolution of symptoms of eyelid ptosis post-surgery and good long-term symmetry of the palpebral aperture and crisp upper eyelid creases. The formula for estimating the fixation point on the levator was accurate to within +/- 1mm in the majority of patients. Our aperture revision rate was 2%. Conclusions This novel technique provides a predictable and reliable approach for upper eyelid ptosis correction in Asian patients.

Outcomes of enucleation and porous polyethylene orbital implant insertion in patients with paediatric retinoblastoma: a long-term follow-up study

Background/AimsTo report the long-term outcomes of enucleation and insertion of porous polyethylene (PP) orbital implant according to the evolving surgical techniques and implant in patients with paediatric retinoblastoma .MethodsPatients with paediatric retinoblastoma who underwent enucleation and PP implant insertion from December 1998 to December 2014 were retrospectively reviewed and divided into four groups: group A, classic enucleation +PP implant; group B, enucleation +PP implant +anterior closure of the posterior Tenon’s (ACPT) capsule; group C, enucleation +PP implant +free orbital fat graft +ACPT and group D, enucleation +smooth surface tunnel PP implant +ACPT. Survival analysis of implant exposure and eyelid malpositions was performed.ResultsOne hundred and ninety-eight eyes of 196 patients were included. The median follow-up period was 13.0 years (range, 5.0–21.1). A 20 mm implant was inserted for 149 eyes (75.3%). The 10-year exposure-free survival probabilities were 44.6% in group A, 96.4% in group B, 97.4% in group C and 97.7% in group D. ACPT was associated with significant reduction in implant exposure (p<0.001). The most common eyelid malposition was upper eyelid ptosis (24.2%). The eyelid malposition-free survival probability did not differ among the four groups. However, the insertion of a 20 mm implant was associated with significant reduction in upper eyelid ptosis and lower eyelid entropion (p=0.004 and 0.038, respectively).ConclusionsThe long-term postenucleation implant exposure was rare after PP implant insertion and ACPT, even with a 20 mm-diameter implant. A larger implant can be beneficial in long-term prevention of eyelid malposition.

Brainstem abscess treated conservatively

Background: Brainstem abscess is a rare condition with a variety of treatment approaches. In this paper, we report an unusual case of a brainstem abscess with a positive outcome in an immunocompetent patient who was treated with antibiotic therapy. Case Description: A 22-year-old female presented with bilateral tetraparesis that was worse on the left hemibody, appendicular tremor, and left upper eyelid ptosis. Brain magnetic resonance imaging showed an abscess in the pons and midbrain due to possible nocardiosis. She was treated with dexamethasone, phenytoin, vancomycin, and meropenem for 8 weeks and trimethoprim-sulfamethoxazole for 6 weeks. The brain injury decreased, and the patient’s neurological status significantly improved. Conclusion: Brainstem abscess may be treated conservatively, leading to improvement of the clinical condition and decreased lesion size on imaging.

A Novel Endoscopic Forehead Lift Technique for Patients with Upper Facial Wrinkles: Morphometric Evaluation and Patient-Reported Outcome using FACE-Q Scales

Chinese patients more frequently complain of forehead wrinkles than eyebrow and upper eyelid ptosis. Besides the commonly used brow-lifting technique, a novel technique to satisfy the demands of Chinese patients is needed. In this article, we introduce our novel endoscopic forehead lift procedure and analyze the morphometric evaluation and patient-reported outcomes. From January 2010 to January 2017, 171 Chinese patients underwent endoscopic forehead lift in which two parallel incisions were made on the frontalis muscle to relieve forehead wrinkles. Biopsy forceps were used to bite off the glabella muscles to relieve wrinkles between the eyebrows. Lifting devices were not used. Morphometric evaluations of eyebrow locations were performed, and the vertical distance of the upper eyebrows was measured post- and preoperatively to evaluate the elevation range. FACE-Q scales were sent to patients who were still being followed-up. A total of 46 patients underwent the morphometric evaluation, which suggested that the eyebrows were elevated effectively. At 12 to 36 months postoperatively, the median post-/preoperative ratio was 118.4, 112.5, and 111.8% in the medial, middle, and lateral eyebrows, respectively. In the same patients, at 37 to 84 months postoperatively, the median post-/preoperative ratio was 116.6, 112.2, and 108.9% in the medial, middle, and lateral eyebrows, respectively. Sixty-five patients completed the FACE-Q scales, demonstrating high satisfaction levels with the forehead and eyebrow, outcome, and decisions, with a median score of 100 for each. Postoperative appraisal revealed that the lines in the forehead and between the eyebrows had a good outcome with scores of 86 and 93, respectively. The median number of years younger that patients thought they appeared was 7. The most frequent self-claimed recovery symptom was temporary forehead skin numbness (83.1%) followed by a receding hairline (46.2%). Our endoscopic forehead lift procedure was effective in relieving forehead and glabella wrinkles and lifting the eyebrows. This was a level of evidence III study.