The utility of margin-reflex distance in determining the type of surgical intervention for congenital blepharoptosis

Function of levator palpebrae superioris in dry eye disease

PURPOSE

To evaluate the effect of levator palpebrae superioris in patients with dry eye disease.

METHODS

168 eyes of 84 patients (group 1 = fair levator function ≤ 9 mm, 78 eyes; group 2 = good levator function > 9 mm, 90 eyes) were retrospectively enrolled. Levator function test, Ocular Surface Disease Index Questionnaire (OSDI), Schirmer I test, noninvasive tear break up time (NItBUT), corneal staining score, meibography, meibum quality and expressibility scores, tear meniscus height, and partial blinking rate (PBR) were examined.

RESULTS

There was no statistically significant differences between group 1 (0.45 ± 0.76) and 2 (0.58 ± 0.76) according to OSDI and corneal stain (P > 0.05). PBR and NItBUT in group 2 (9.29 ± 4.01 and 4.76 ± 2.39, respectively) were significantly worse than those in group 1 (5.88 ± 3.99 and 5.78 ± 2.94, respectively) (P < 0.05). There was a significantly positive correlation between levator function and partial blinking rate (R = 0.4114, P = 0.0002). Meibum expressibility and lipid thickness in group 2 (0.48 ± 0.70 and 1.39 ± 0.45, respectively) were significantly better than those in group 1 (1.29 ± 0.65 and 1.12 ± 0.33, respectively) (P < 0.05) (Fig. 3). There was a significantly negative correlation between levator function and meibum expressibility grade (R = -0.3869, P = 0.0006) (Fig. 5).

CONCLUSION

The eyes with good levator function showed shorter tear break-up time due to a higher partial blinking rate, but showed better lipid thickness due to better meibum expressibility compared with the eyes with fair levator function. Evaporative dry eye disease in the eyes with good levator function can be compensated for by a better meibum expressibility.

Facial Anthropometric Measurements and Principles - Overview and Implications for Aesthetic Treatments

Facial anatomy is highly individual in each patient. Anthropometric measurements can be a useful tool to objectively analyze individual facial anatomy to allow for better comparability before and after treatments to ultimately improve standardization of facial procedures, both nonsurgical and surgical. The aim of this study was to provide a comprehensive overview over clinically relevant and feasible facial anthropometric measurements and principles for aesthetic medicine. A literature review was conducted to describe the most important and clinically relevant anthropometric measurements and principles for both the entire face and for three aesthetically relevant facial regions: the periorbital region, the nose, and the perioral region. A multitude of different anthropometric measurements and principles have been described in the literature for both the overall facial appearance and specific facial regions. Certain generally accepted anthropometric principles and proportions need to be respected to achieve aesthetic and harmonious results. For the overall facial appearance, a focus on symmetry, certain proportions, facial angles, and indices has been described. Principles and measurements were also described for the periorbital region, the nose, and the perioral region. Although attractiveness and aesthetic perception are subjective, objective evaluation of facial surface anatomy via anthropometric measurements can improve pre- and postinterventional analysis of the face and help the treating physician to individualize treatments, both nonsurgical and surgical.

Sector area index: a novel supporting marker for blepharoptosis screening and grading

PURPOSE

To introduce a new supporting marker for discriminating different grades of ptosis called Sector Area Index (SAI) and a semi-automated technique to calculate it.

METHODS

In this cross-sectional comparative case series, a circle enclosing the intercanthal distance was automatically drawn after choosing two points as the medial and lateral canthus and manually selecting the palpebral fissure region. Finally, 15-degree apart sectors are applied to the enclosed circle. SAI was measured automatically by dividing the area of each 15-degree sector marked with the upper eyelid contour by the total area of the sector marked with the edge of the surrounding circle. SAI values and inter-eye SAI differences were compared between patients with different grades of ptosis as well as normal patients.

RESULTS

In the current study, 106 eyes were recruited (30, 25, 27, and 24 in the control, mild, moderate, and severe ptosis groups, respectively). Mean values of SAI in all sectors showed a decreasing trend from normal individuals toward patients with severe ptosis. The mean difference values of SAI between study eyes and fellow eyes in all four groups of patients showed a statistically significant difference (p < 0.05). In a pairwise comparison between groups, mean values of SAI in all nasal sectors from 15° to 60° showed a statistically significant difference between all groups (p < 0.05).

CONCLUSION

The mean difference of SAI between study eyes and fellow eyes, including eyelid curvature, especially in 15°-60° and 120°-165° sectors, can demonstrate differentiating performance for detecting and discriminating varying grades of ptosis.

Objective quantification of the impact of blepharoplasty on the superior visual field

Background

Blepharoplasty has both aesthetic and functional benefits in patients with pseudoptosis; however, previous studies could not demonstrate its beneficial effects quantitatively and objectively. The authors objectively analyzed the visual field before and after surgery and investigated whether measurements of the visual field can be applied as a suitable predictor of surgical outcomes.

Methods

In total, 18 eyelids in nine patients with pseudoptosis who had undergone simple skin excision blepharoplasty were evaluated prospectively from February to May 2016. The visual fields were analyzed preoperatively and 3 months postoperatively using the Goldmann kinetic perimetry test. The visual field test area was assessed using Adobe Photoshop.

Results

Blepharoplasty had an average 4.99-fold beneficial effect on the superior visual field. In particular, more improvement was seen in the superior temporal quadrant than in the nasal quadrant. No correlation was found between the preoperative margin-to-reflex distance 1 (MRD1) and the surgical outcome (P=0.119). However, there was a strong correlation between the preoperative superior visual field and the surgical outcome (P=0.001).

Conclusions

Using the Goldmann kinetic perimetry test, we objectively and quantitatively proved the beneficial effect of blepharoplasty on patients with pseudoptosis. Furthermore, we demonstrated that the preoperative visual field is a better preoperative surgical outcome predictive factor than the preoperative MRD1.

Factors Affecting the Outcome of Frontalis Sling Surgery in Patients with Severe Blepharoptosis

Background:

Several factors play a role in the outcome of severe blepharoptosis correction by frontalis sling surgery, including the age of a patient, sex, causes of ptosis, and its severity, among others. Identifying the factors that most severely affect surgical outcomes could reduce the complication rate and improve patients’ satisfaction.

Methods:

This was a retrospective analytical study using logistic regression statistics to evaluate the effects of the following 6 factors on frontalis sling surgical outcomes: age, sex, cause of ptosis, type of anesthesia used, eye side (right or left), degree of ptosis, and levator function. These factors were compared with 10 types of surgical outcomes. The study included 120 eyelids in 95 patients, of which 70 eyelids were unilateral and 50 eyelids were bilateral. Patient ages ranged between 2 and 75; patient sex distribution was 47.5% females and 52.5% males.

Results:

The study yielded 60 comparison tables. Only statistically significant and clinically relevant data are presented and discussed. Overall, male patients showed better eye symmetry (P < 0.026) and better satisfaction (P < 0.004) than did females. Causes other than the congenital ptosis are characterized by better eye closure during sleep (P = 0), in comparison with congenital ptosis cases.

Conclusion:

The use of silk suture as a sling material is recommended for male patients, as its use produces better results, including eye symmetry and patient satisfaction, with a lower complication rate compared with that in female patients.

Outcomes of Early Correction of Congenital Myogenic Ptosis Using Transconjunctival Levator Plication

Introduction:

Early correction of congenital ptosis may be indicated due to a risk of amblyopia or because of an abnormal head tilt. One of the main problems, of planning ptosis surgery in very young children, is the inability to measure the levator function.

Aim:

The aim of the article was to analyze the early correction of congenital myogenic ptosis.

Methods:

This was a retrospective, interventional, case series study, conducted on 12 eyes of 12 patients with unilateral, mild to moderate, congenital myogenic ptosis. Surgical correction of ptosis was performed by transconjunctival levator muscle plication. Pre- and postoperative measurements of the upper lid margin to central corneal reflex (MRD1) and upper lid skin crease height (UEC) were obtained, as well as the presence or absence of a reaction to topically applied phenylephrine 2.5% solution.

Results:

The mean age of the patients was 29.83 months (range 14-45 months). A negative phenylephrine test was noted in only 3 (25%) of cases. Equalization of upper lid height was achieved in 6 (50%), and a hypocorrection of up to 1 mm was noted in 4 (33%) of patients. There was only 1 hypercorrection of 1 mm, noted in the first postoperative month. In one case of hypocorrection of 2 mm, the height of the lid dropped between the 1 and 3 months follow up. Subsequent revision surgery was performed, with a good outcome. With regard to the upper lid skin crease height (UEC), the mean preoperative difference in relation to the contralateral (non-operated) lid, was 2.16 mm, whereas the average postoperative or final difference was 0.41 mm.

Conclusion:

Correction of myogenic ptosis in small children, using transconjunctival levator plication, in whom levator function cannot be measured, may have a satisfactory postoperative outcome.

Long-term functional and aesthetic evaluation of using a single rhomboid-shaped fascial strip for severe congenital unilateral blepharoptosis

PURPOSE

Surgery for congenital blepharoptosis is often performed at approximately 4-5 years of age. A long-term follow-up is important during facial growth. We performed frontal suspension by using a single rhomboid-shaped autogenous fascial strip. We conducted a long-term evaluation of patients with severe congenital unilateral blepharoptosis.

PATIENTS AND METHODS

A total of 334 patients with congenital blepharoptosis underwent surgery between 1994 and 2006. Of these, 192 patients had unilateral blepharoptosis with levator function less than 3 mm. A retrospective analysis was conducted on those patients who could be followed up postoperatively for at least 10 years and had accurate clinical photographs available. Visual acuity, palpebral fissure height (PFH), and marginal reflex distance (MRD) were evaluated from the photographs to compare both eyes. PFH and MRD were assessed as ratio. Morphological evaluation was based on patient and family comments. Statistical analysis included the t-test.

RESULTS

Participants comprised 95 patients (63 male and 32 female; 43 left and 52 right). Visual acuity showed improvements. Although the postoperative MRD ratio of the affected eye was significantly improved, no clinically significant bilateral difference was seen in postoperative PFH, compared with those in the unaffected side. The surgical results were as follows: 62 excellent, 14 good, 12 fair, 3 poor, and 4 other cases in our criteria. No major complications occurred. Satisfactory result could be seen in 76 of the 95 cases.

CONCLUSION

The evaluation results show that our surgical procedure appears useful for patients with unilateral congenital ptosis. Moreover, blepharoptosis surgery is useful for improving visual acuity. In this paper, we report this surgical procedure and discuss its long-term results.