Results and complications of silicone frontalis sling surgery for ptosis

Delayed infections following polybutylate-coated polyester (Ethibond) suture frontalis suspension surgery for severe blepharoptosis

PURPOSE

To describe the incidence and management of delayed infections following frontalis sling suspension with polybutylate-coated polyester suture (Ethibond).

METHODS

Retrospective, interventional case series of 177 eyes of 150 patients, who underwent frontalis suspension surgery with Ethibond (Johnson and Johnson, USA), at L V Prasad Eye Institute, Hyderabad, India, between January 2016 and February 2022. Patients were assessed for chronic secondary sling infection, defined as infection/suture granuloma occurring beyond 6 weeks post-surgery. All patients received postoperative oral antibiotics. The clinical profile, microbiological evaluation, antibiotic sensitivity patterns, and management outcomes were analyzed.

RESULTS

Delayed infection following Ethibond sling suspension was noted in 14 eyes of 13 patients (7.9%). Of these, eight cases (61.5%) were females. The average time interval from surgery to presentation was 7.5 months (range: 2.5 months to 2.5 years). Eleven eyes underwent sling removal. Of the three who received initial antibiotic course, two eventually needed sling removal. Microbiological evaluation was available in seven eyes (50%), with Staphylococcus aureus as the most common organism. Of the six positive cultures, five (83.3%) were resistant to fluoroquinolones (FQs).

CONCLUSION

Frontalis suspension with Ethibond has an 8% incidence of delayed infections, with Staphylococcus aureus as the most common organism. The authors recommend early sling removal in all patients with infection and recommend consideration of an alternative material in the event of future revision surgery.

Frontalis Sling Using a Silicone Rod for Ptosis in Third Nerve Palsy: Cosmesis Versus Safety

Purpose

To evaluate the results of the frontalis sling operation using a silicone rod for the correction of ptosis in patients with third nerve palsy with a focus on corneal safety.

Methods

Patients with third nerve palsy who underwent the frontalis sling operation using a silicone rod between 2008 and 2019 were included in this study. The medical records of all patients were reviewed, and their clinical characteristics and postoperative outcomes were analyzed. In this retrospective, interventional case series, the main outcome measures were eyelid contour, eyelid height by margin reflex distance, and corneal status.

Results

Twenty-four eyes of 18 patients (12 male and six female patients) were included. The mean age at the time of surgery was 35.1 years (range, 5–64 years). Twelve patients underwent a unilateral ptosis operation, and six patients received a bilateral ptosis operation. The mean follow-up period was 32.1 months (range, 2–87 months). Most patients (21 of 24 eyes, 88%) showed poor Bell’s phenomenon on preoperative examination. Satisfactory eyelid height and eyelid contour were achieved in almost all patients (mean postoperative margin reflex distance, +1.2 mm) postoperatively. Although corneal erosions were detected for several months in eight of 24 eyes after surgery, these findings were well controlled medically with artificial tear eye drops and ointments.

Conclusions

Frontalis sling surgery using a silicone rod can safely and effectively correct ptosis without severe corneal complications in patients with third nerve palsy. Our study outlines a new method to define the postoperative safety outcome by specifically focusing on categorized corneal status.

The Application of Temporal-Fasciae-Complex Sheet in Treating Severe Blepharoptosis

AIM

To introduce the application of the temporal-fasciae-complex sheet in treating severe blepharoptosis by frontalis suspension and evaluate its postoperative effect.

METHODS

Between 2008 and 2016, 25 patients (33 eyelids) underwent this procedure. A 3-cm incision in the temporal region was made to harvest a sheet of deep temporal fascia with the loose aponeurosis attached on both sides. The sheet was then grafted through a preseptal tunnel to perform the suspension. The margin reflex distance 1 after suspension (MRD1S), the margin reflex distance 1 as lifting eyebrow forcefully (MRD1F), the eyelid excursion and the closable eyelid function were used to evaluate the postoperative effect.

RESULTS

A total of 22 patients (30 eyelids) completed the study with a mean follow-up period of 23 ± 8.78 months. There was a statistically significant difference between the MRD1 and MRD1S (p < 0.05), the preoperative and postoperative MRD1F (p < 0.05), the preoperative and postoperative eyelid excursion (p < 0.05). All the upper palpebral margins were located above the pupils and no longer affected visual acuity in primary gaze. No severe complication and recurrence were documented within a maximum follow-up period of 36 months.

CONCLUSIONS

Frontalis suspension with the temporal-fasciae-complex sheet is an efficient method to correct severe blepharoptosis with less complications and recurrences. The application of the sheet can not only overcome the influence of adhesion but also lift the eyelid both functionally and cosmetically.

LEVEL OF EVIDENCE IV

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 .

Double Rhomboid Suture Technique for Congenital Ptosis

PURPOSE

Congenital ptosis is a troubling eye condition for pediatric ophthalmologists. There are many considerations to contemplate when deciding when to operate and which technique to use.

METHODS

A retrospective chart review of 69 pediatric patients treated for congenital ptosis using a double rhomboid frontalis sling with a nylon suture at a single tertiary care center.

RESULTS

For patients with more than 6 months of follow-up, there were 38 patients with 46 primary surgeries (22 [58%] males and 16 [42%] females). The average age at the first surgery was 39.34 ± 33.18 months. There was a mean follow-up time of 51.87 ± 53.79 months. There were 7 children who needed one revision and 1 child who needed a second revision, equaling a 23.9% rate of revision. Patients who had surgery before the age of 3 years had a statistically significant likelihood of needing a second surgery (chi-square test = 7.246, P = .007, 95% confidence interval = 0.027 to 0.687). It was also statistically significant (P < .05) that, throughout childhood, older patients were less likely to need a revision.

CONCLUSIONS

A double rhomboid frontalis sling using a nylon suture is an effective technique to treat congenital ptosis. This technique is easy to master and has a low cost compared to techniques involving autografts and allografts. It is also important to advise the family of the likelihood of a second surgery if there is a need to operate at a young age. [J Pediatr Ophthalmol Strabismus. 2018;55(2):117-121.].

Efficacy of brow suspension with autogenous fascia lata in simple congenital ptosis

Objective:

To assess the mean change in interpalpebral fissure height and marginal reflex distance after brow suspension with autogenous fascia lata sling in patients of ptosis.

Methods:

This was a Quasi experimental study conducted at Department of Ophthalmology, Mayo Hospital, King Edwards Medical University Lahore, from Jan 2013 to June 2016. Included were the patients who had unilateral or bilateral ptosis with poor levator function (< 5 mm). Informed consent was obtained from all patients after explaining about the research project. Patients were admitted in ward and all of them underwent surgery by a single surgical team. The surgical procedure was performed in supine position under general anesthesia in children and uncooperative patients. Patients were followed at week 4, 8, 12 and 24 to observe vertical interpalpebral fissure height and marginal reflex distance.

Results:

The mean age of the patients was 9.03 ± 5.26 years. The mean Inter palpebral fissure height (IPFH) was 4.40±0.91 mm and mean MRD was 0.50 ± 1.00 mm before surgery while after surgery it was 7.41±0.76 mm and 3.10 ± 1.50 mm respectively at 04 weeks. The mean IPFH and MRD at 24 weeks postoperatively were 8.43±0.98 mm and 3.60 + 1.50 mm respectively. The mean change in IPFH and MRD at 24^th week, were 3.90 ± 0.34 mm and 3.50 ± 1.00 mm.

Conclusion:

Brow suspension with fascia lata sling is safe and effective technique for correction of ptosis with poor levator function.

Analysis of the causes of recurrence after frontalis suspension using silicone rods for congenital ptosis

Background

Silicone rod is a commonly used synthetic suspension material in frontalis suspension surgery to correct blepharoptosis. The most challenging problem and a decisive drawback of the use of silicone rod is a considerable rate of ptosis recurrence after surgery. We examined patients with recurred ptosis and assessed the physical and micromorphological properties of implanted silicone rods to determine the causative mechanisms of recurred ptosis after frontalis suspension using silicone rod.

Methods

This is a prospective observational case series of 22 pediatric patients with recurred ptosis after frontalis suspension using silicone rods for congenital ptosis. Implanted silicone rods were observed and removed during the operation for correction of recurred ptosis. The removed silicone rods were physically and micromorphologically evaluated to determine the cause of recurrence.

Results

Pretarsal fixation positions migrated upward, whereas suprabrow fixation positions migrated downward during ptosis recurrence. The breaking strength of implanted silicone rods was reduced by approximately 50% during 3 years. Cracks, debris, and loss of homogenous structure with disintegration were observed on scanning electron micrographs of implanted silicone rods in patients with recurred ptosis. Preoperative severe degree of ptosis also contributed to recurred ptosis.

Conclusions

Recurrence of ptosis after frontalis suspension using silicone rod was associated with physical changes of implanted silicone rods, including positional migration, weakened tensile strength, and micromorphological changes in combination with patients’ characteristics.

Outcomes of Two Surgical Techniques Using Silicone Rod for Frontalis Sling Suspension to Treat Severe Ptosis

PURPOSE

To compare outcomes of two techniques of frontalis silicone sling surgery.

METHODS

This retrospective, nonrandomized chart review was performed on patients undergoing frontalis sling surgery between 2008 and 2011. Silicone rods were sutured to the tarsal plate through an eyelid crease incision (open method) or stab incisions (closed method). Data were collected on age, gender, type of surgery, preoperative and postoperative margin reflex distance (MRD), and complications. A successful outcome was defined as a postoperative score of 2 to 4 for MRD or an improvement in MRD.

RESULTS

A total of 155 eyelids of 146 patients with ptosis were included. There were 60 patients in the open method group and 85 patients in the closed method group, respectively. Successful outcomes were seen in 30 (50%) patients in the open method and 44 (51.8%) patients in the closed method groups. There were 61 (71.8%) patients in the open method group and 45 (75%) patients in the closed method group who had improved MRD at last follow-up. The main complications were exposure keratitis, eyelash ptosis, and eyelid crease abnormalities that occurred only in the closed method group.

CONCLUSIONS

The silicone frontalis sling procedure had the same success rates in both the open and closed methods. Eyelash and eyelid crease abnormalities were unique to the closed method. [J Pediatr Ophthalmol Strabismus. 2017;54(1):52-58.].

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.

Frontalis Sling Surgery With IBCN-Ritleng Probe: A New Technique With a 20-Gauge Catheter

INTRODUCTION

Frontalis sling surgery is the reference procedure for severe ptosis due to poor Levator function. Autologous or synthetic materials are used for lifting the upper eyelid.

OBJECTIVE

To describe a new technique of passage of a silicon wire through a 20-gauge intravenous catheter and to explore literature.

METHODS

A 83-year-old male patient with simple, severe ptosis with previous levator resection surgery (7 month before) had frontalis sling with a silicone IBCN wire placed under local anesthesia with a closed technique. It consisted in realization of 3 punctiform incisions upper the eyebrow, through which a 20G intravenous catheter was inserted and droven to the free border of the upper eyelid. The polypropylene part of the IBCN probe silicone tube, IBCN set, was interlocked into the needle tip, enabling to drag the wire through its tunnel without eyelid dissection. The body of the IBCN probe was consequently placed on the free edge of the eyelid, whereas its 2 ends were tied under the middle upper eyebrow incision, enabling to adjust tension of the probe according to the severity of ptosis. The node was kept subcutaneously, allowing correction "on demand" of wire tension in the future by the surgeon.

RESULTS

No infections, exposures, or granuloma formations were seen in our patient at 2 months, whereas visual field was improved and the patient fully satisfied.

DISCUSSION

Small punctiform incisions and limited skin dissection offer a significant advantage, as well as the materials that are easy to access and cheap, in the frontalis sling surgery.

CONCLUSION

The authors added to frontalis sling surgery a simple and cost-effective alternative technique of passage of a subcutaneous probe, with an IBCN wire whose dimensions fit perfectly a 20-gauge intravenous catheter and allowing later correction "on demand" of the ptosis.