Comparison of Mersilene mesh and autogenous fascia lata in correction of congenital blepharoptosis: a randomized clinical trial

Use of autogenous fascia lata slings in the surgical correction of ptosis: a systematic review of the literature and meta-analysis

Ptosis is an abnormally low-positioned upper eyelid. Management depends on severity, aetiology, and function of the levator palpebrae superioris muscle (LPS). This review evaluates the success of autogenous fascia lata slings (AFLS) in the surgical management of ptosis, together with complication and reoperation/revision rates. A literature search was conducted on PubMed, Google Scholar PROSPERO, Dynamed, DARE, EMBASE, Cochrane, and BMJ databases (PROSPERO registration: CRD42023475090), and 30 studies (3690 patients and 5059 eyes) were included. The average age of the patients was 14.2 years with a ratio of male:female patients of 1:0.7. A total of 2532 eyes had undergone a fascial sling with autogenous fascia lata. The average follow-up period was 32.6 months. Improvement in the margin to reflex distance 1 (MRD1) with fascial sling surgery was 2.79 mm. The rate of complications from surgery involving autogenous fascia lata was 21.3%. The most common complications included lagophthalmos (19.8%), residual ptosis (11.5%), and corneal damage (10.4%). The reoperation rate was 13.4%. Most common indications for reoperation were cosmetic, with asymmetry (18%), lid crease abnormalities (30%), and upper eyelid trimming (18%). The overall complication rate in AFLS patients was 20% (95% CI: 6 to 35, p < 0.01; I2 = 89%) versus 27% (95% CI: 14 to 40, p < 0.01; I2 = 90%) in non-AFLS patients. AFLSs are prudent in the surgical management of ptosis. The results of this review demonstrate that their use is associated with similar complication rates but fewer reoperations than other traditional techniques.

Surgical Interventions for Congenital Ptosis: a Systematic Review and Meta-analysis of 14 Randomized Controlled Trials

BACKGROUND

Several types of surgeries have been used in the treatment of congenital ptosis, but the optimal methods and materials for this treatment are unknown.

PURPOSE

The study aims to evaluate the comparative effectiveness and safety of various surgical methods and materials for treatment of congenital ptosis.

METHODS

We performed comprehensive searches of five databases, two clinical trial registries and one gray literature database from inception to January 2022 for related trials to include in this study. Meta-analysis was performed to evaluate the effect of surgical methods and materials on the primary outcomes: margin reflex distance 1 (MRD1), palpebral fissure height (PFH), and degree of lagophthalmos; and secondary outcomes: undercorrection, entropion, corneal epithelial defects, wound dehiscence, recurrence, infection, and cosmetic outcomes.

RESULTS

A total of 14 trials evaluating 909 eyes of 657 patients were included in our study. Compared with the levator plication, the frontalis sling significantly increased the MRD1 (MD = - 1.21; 95% CI [- 1.69, - 0.73]), and the levator resection significantly increased the PFH (MD = 1.30; 95% CI [0.27, 2.33]). For the frontalis sling surgical patterns, the fox pentagon was significantly better than the double triangle at improving the degree of lagophthalmos (MD = 0.70; 95% CI [0.32, 1.08]), while the opened pattern provided statistically better cosmetic outcome than the closed frontalis sling. Analysis of surgical material showed that absorbable sutures significantly increased the MRD1 (MD = 1.16; 95% CI [0.60, 1.72]) compared to non-absorbable sutures when used in levator plication; frontalis sling surgeries performed with silicon rods significantly increased the PFH (MD = 0.88; 95% CI [0.29, 1.47]) compared to those performed with Gore-Tex strips, while autogenous fascia lata provided statistically better aesthetic outcome for lid height symmetry and contour.

CONCLUSION

Different surgical methods and materials appear to affect different aspects of the congenital ptosis treatment outcome.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Survey of ptosis practice patterns among surgeons in Asia Pacific Society of Ophthalmic Plastic and Reconstructive Surgery (APSOPRS)

OBJECTIVE

To characterize the preferred ptosis practice patterns and variations among oculoplastic surgeons in the Asia-Pacific region.

METHODS

A web-based questionnaire was sent to both members and non-members registered under the Asia Pacific Society of Ophthalmic Plastic and Reconstructive Surgery (APSOPRS)'s email database. The survey included preoperative testing practices, surgical preferences for adult aponeurotic and congenital ptosis, various surgical techniques (anterior and posterior approach ptosis procedures, and frontalis sling procedures) and postoperative practices.

RESULTS

A total of 386 survey invitations were sent. There was a response rate of 68.7% from respondents from 20 countries in the Asia-Pacific region. There was variation in the preoperative evaluation and management of ptosis. Anterior approach ptosis surgery (96.6%) and frontalis sling procedures (86.8%) were performed by more surgeons than posterior approach ptosis surgery (47.2%). There was a deviation from the traditional frontalis sling procedures for patients with poor levator function.

CONCLUSIONS

Our survey results provide insight into the variation in the assessment and management of ptosis amongst oculoplastic surgeons in the Asia-Pacific region. It also demonstrates some differences between practice patterns in Asia-Pacific and America.

Single-triangle versus Fox pentagon frontalis suspension for unilateral severe congenital ptosis correction

PURPOSE

To compare the functional and cosmetic outcomes of two different frontalis sling techniques for correction of severe unilateral congenital ptosis: single triangle and Fox pentagon techniques using expanded polytetrafluoroethylene (ePTFE) suture.

METHODS

This randomized controlled trial included 60 eyes of 60 patients with severe unilateral simple congenital ptosis and poor levator function (≤4 mm). Participants were randomly assigned for either single triangle or Fox pentagon frontalis suspension using ePTFE suture. Functional outcome measures were margin reflex distance (MRD1), palpebral fissure height (VFH), and lagophthalmos. Cosmetic outcome parameters (lid contour, lid crease, and height symmetry) were graded as 3 (excellent), 2 (good), or 1 (poor), with a minimum of 18 months' follow-up.

RESULTS

At final follow-up, there was a significant improvement in the MRD1 and VFH in both groups, with no statistical difference (P = 0.9). Both groups showed comparative cosmetic results regarding lid height symmetry, crease, and contour. The patients in the single-triangle group showed more rapid recovery of postoperative edema and lagopthalmos with less visible forehead scarring. There were no serious ePTFE sling-related complications.

CONCLUSIONS

In our study cohort, the single-triangle and Fox pentagon frontalis suspension techniques had similar outcomes with respect to MRD1 and VFH and comparable cosmetic results. However, the single-triangle technique avoids two forehead incisions and was associated with less postoperative edema, lagophthalmos, and scarring.

Types of materials for frontalis sling surgery for congenital ptosis

BACKGROUND

Congenital ptosis is a drooping of one or both eyelids at birth, often due to poor development of the levator palpebrae superioris muscle. This can result in amblyopia, astigmatism, and ocular torticollis and therefore may necessitate surgical intervention in early childhood if visual development is compromised. Patients may have varied levels of levator function. Those with moderate to good function may elect to first attempt ptosis repair with external levator advancement or mullerectomy/Fasanella-Servat procedures. For those with poor function, those procedures are less likely to be effective, so they may undergo frontalis sling surgery, in which the tarsal plate is coupled to the frontalis muscle, so that movement of the brow and forehead result in movement of the eyelid. The optimal material to use in this surgery is unknown.

OBJECTIVES

To evaluate the comparative effectiveness and safety of various materials used in frontalis sling surgery for congenital ptosis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (June 2018), Ovid MEDLINE, Ovid MEDLINE E-pub Ahead of Print, Ovid Medline In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily (January 1946 to 20 June 2018), Embase (January 1947 to 20 June 2018), PubMed (1948 to 20 June 2018), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to 20 June 2018), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 20 June 2018.

SELECTION CRITERIA

We included randomized trials that compared one material to another for the treatment of congenital ptosis.

DATA COLLECTION AND ANALYSIS

Two review authors independently completed eligibility screening, data abstraction, 'Risk of bias' assessment, and grading of the evidence.

MAIN RESULTS

We identified three randomized trials that had compared four different materials, two materials in each trial. The studies included a total of 160 participants. The surgical procedures compared were polytetrafluoroethylene (Gore-Tex), Ethibond suture, Mersilene mesh, and autogenous fascia lata.We judged all studies to be at unclear risk of bias due to incomplete reporting of methods and other methodological deficiencies.Because the three included studies compared different types of implants, we were unable to combine data in a meta-analysis. The limited data preclude any conclusion regarding the optimal implant for frontalis sling surgery.In terms of the primary outcome of functional success, this was defined as widening of the opening between eyelids, assessed either by grade or by millimeter measurement. Bajaj 2004 showed that 93% of the Gore-Tex group and 83% of the Ethibond group had a good or satisfactory outcome (as defined by investigators). Elsamkary 2016 reported that 78.1% of the autogenous fascia group and 61.8% of the Gore-Tex group had a very good or good outcome. Salour 2008 did not include this type of grading system; they showed that the lid fissure increased 4.0 mm ± 1.46 mm in the Mersilene group and 3.13 mm ± 1.72 mm in the fascia lata group.In terms of adverse events, Bajaj 2004, which included 15 patients per group, showed no recurrence in the Gore-Tex group and 1 in the Ethibond group; no need for removal in the Gore-Tex group and 1 in the Ethibond group; and no infections in the Gore-Tex group and 1 in the Ethibond group. Elsamkary 2016, which included 55 patients per group, had 3 recurrences in the fascia group and 6 in the Gore-Tex group; no need for removal in either group; and 1 infection in the fascia group and 2 in the Gore-Tex group. Salour 2008, which included 10 patients per group, had no recurrence, removals, or infections in either the Mersilene or the fascia group.

AUTHORS' CONCLUSIONS

The three trials included in this review evaluated four materials for frontalis sling surgery. Assessment of these three studies does not allow us to identify the optimal material. Future randomized trials should be rigorously designed so as to identify the best treatment for this condition.

Suspensory Materials for Surgery of Blepharoptosis: A Systematic Review of Observational Studies

BACKGROUND

Frontalis suspension surgery is considered the procedure of choice in cases of blepharoptosis. Among all the materials used in this type of surgery, ophthalmic and plastic surgeons prefer to use autologous Fascia Lata. However, during years, other autogenous and exogenous materials have been introduced.

OBJECTIVES

The aim of this study was therefore that of systematically reviewing the functional results and the rate of complications of different synthetic materials, as compared to autogenous Fascia Lata. The primary objective was to determine the rates of Successful Surgeries (SSs) of these materials. The secondary objective was to assess the onset of complications. The following materials were investigated: Fascia Lata, Mersilene, polytetrafluoroethylene (PTFE) and Silicon.

DATA SOURCE AND METHODS

Following the Prisma procedure, on January 30th, 2016 we used the following electronic databases to select the studies: MEDLINE and Scopus.

RESULTS

The search strategy retrieved 48 publications that met the eligibility criteria of the systematic review. All studies were non-comparative. PTFE (n = 5) showed the best rate of SSs among the materials compared (statistically significant). Surgeries performed with autogenous Fascia Lata (n = 19) had a 87% rate of success those performed with Mersilene (n = 12)had 92% and those performed with Silicon (n = 17)88%. PTFE had the best outcome, with 99% success rate. As for complications, surgeries performed with PTFE had a higher rate of suture infections (1.9%) as compared to Fascia Lata, but lower incidence for all other complications.

CONCLUSIONS

Although most studies were good quality cohort studies, the overall quality of this evidence should be regarded as low due to their non-comparative design. Our data suggest that PTFE seems to be the most valid alternative material for frontalis suspension surgery, with low recurrence rates and good cosmetic and functional results.

Functional centre of the upper eyelid: the optimal point for eyelid lifting in ptosis surgery

AIMS

To establish the novel concept of a functional eyelid centre to determine the optimal point for eyelid lifting in ptosis surgery.

METHODS

This was a prospective study of 112 patients with congenital ptosis. The functional eyelid centre was defined as the point where the eyelid contour showed the best appearance when the upper eyelid was lifted manually. In patients who underwent frontalis suspension surgery using silicone rods, the postoperative outcome was assessed according to the fixation point of the rod.

RESULTS

The average horizontal fissure width and the distance from the medial canthus to the mid-pupillary line were 21.9 and 10.1 mm, respectively. The functional eyelid centre was located 4.28±0.98 mm temporal to the mid-pupillary line. The outcomes of silicone rod surgeries were excellent when the rod was fixated 4.4 mm nasal and 3.9 mm temporal from the functional eyelid centre. These positions corresponded to 0.1 mm nasal and 8.2 mm temporal from the mid-pupillary line.

CONCLUSIONS

The functional eyelid centre was located slightly temporal to the mid-pupillary line. A better eyelid contour in ptosis surgery is produced when eyelid lifting is centred around the functional eyelid centre.

Intra-eyebrow frontalis suspension using inverted Y-shaped short autogenous fascia lata for blepharoptosis with poor levator function

Frontalis suspension using autogenous fascia lata is a common procedure for blepharoptosis with poor levator function. However, donor-site morbidity associated with fascia lata harvest cannot be ignored. In conventional procedures, the required length of the fascia lata is usually >5-12 cm with a lateral thigh skin incision of approximately 5 cm or more. The present study introduces a new frontalis suspension procedure in which the required size (length and width) of the fascia lata and length of lateral thigh incision is much smaller. The harvested fascia lata is tailored to an inverted Y shape and the separated caudal legs are fixed to the tarsus while the cephalic end is grafted inside the eyebrow through a suborbital septum tunnel. In the present study, 11 patients who underwent the new procedure with a minimum of 6 months of follow-up were evaluated. The average length and width of the harvested fascia lata in unilateral ptosis cases were 2.85 and 0.89 cm, respectively. The average length of the lateral thigh incision was 1.25 cm. The margin reflex distance improved in all cases at 6 months postoperatively. The cosmetic result was graded as good to excellent in most of the patients. Trichiasis, widened donor scar, and eyebrow notch were noted as complications. The present method is a good alternative for the treatment of blepharoptosis with poor levator function. It potentially reduces donor-site morbidity as compared with conventional frontalis muscle suspension procedures using autogenous fascia lata.

Frontalis suspension with supramid suture: longevity results in very young patients with congenital ptosis

PURPOSE

To evaluate the duration of effect of frontalis suspension using Supramid suture (polyfilament, cable-type 3-0 suture) technique in very young children with congenital ptosis.

METHODS

The authors performed a retrospective review of 44 patients aged 4 years or less who underwent frontalis suspension using Supramid at the Bascom Palmer Eye Institute. Surgical success was defined as good eyelid height and position. Duration of the sling was defined as the time from initial surgery until additional surgery was performed or the date of last follow up. Kaplan-Meier survival analysis was performed with failure time measured as time from initial surgery until additional surgery was performed.

RESULTS

Kaplan-Meier survival analysis showed a success rate of 87.5% at 1 year, 78.2% at 2 years, 74.5% at 3 years, 58.2% at 4 years, and 53.7% at 5 years. Complications were noted in 10 cases (23%) and included damage to the Supramid sling secondary to trauma and granuloma formation.

CONCLUSIONS

Given the ready availability, ease of placement, and reliable cosmetic and functional results, Supramid suture is an excellent temporizing treatment option in cases of early amblyogenic congenital ptosis in children <4 years of age. Due to the inherent decline in effect over time and likely need for a secondary procedure at a later age, however, they do not recommend this as an alternative to other sling materials, such as autogenous fascia lata, in patients over 4 years of age.

Open loop fascial sling for severe congenital blepharoptosis

PURPOSE

Severe congenital eyelid ptosis present as a functional and aesthetic problem. The choices of procedures depend mainly on providing an additional elevator force to the upper lid to elevate it, and maintain a reasonable eye opening and vision. We describe a simple open loop fascia lata suspension sling to the frontalis muscle to treat patients with severe eyelid ptosis and poor levator function.

METHODS

Sixty nine lids in 51 patients, were enrolled in this study, all had severe eyelid ptosis and had autogenous fascial sling used for the correction of the ptosis.

RESULTS

The final lid level and contour was evaluated after the follow-up period and showed that the results were satisfactory in 77% of the patients. The unsatisfactory results were due to under correction in 10%, poor lid crease in 6%, lid notch in 4%, and entropion in 3% of the operated lids.

CONCLUSIONS

The accurate evaluation and implementation of this technique can correct the problem of ptosis provided that the patients exercises the frontalis muscle in order to accomplish the desired lid level.

Evaluation of transconjunctival frontalis suspension using nonabsorbable suture

PURPOSE

To evaluate the transconjunctival frontalis suspension technique using nonabsorbable suture (4/0 polypropylene) in patients with severe blepharoptosis and poor levator function.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.