Anterior approach white line advancement: technique and long-term outcomes in the correction of blepharoptosis

Novel use of an autologous scleral button graft to close the anterior defect in evisceration surgery

PURPOSE

To present an alternative evisceration technique with long-term follow-up data. This technique involves the insertion of an acrylic implant into a modified scleral shell which is closed using an autologous scleral graft.

METHODS

This was a retrospective analysis of eviscerations performed in a district-general hospital in the UK. All patients underwent conventional ocular evisceration after total keratectomy. A full thickness scleral graft is harvested from the posterior sclera, using an internal approach, with an 8 mm dermatological punch. An 18-20 mm acrylic implant is placed into the shell, and the scleral graft is used to close the anterior defect. Demographic characteristics, implant size and type, and cosmetic results from pictures of all patients were recorded. All patients were invited for a review to measure motility, eyelid height, patient recorded satisfaction and complications.

RESULTS

Of the five patients identified, one had since died. The remaining four attended a review in person. The mean time between surgery and review was 48 months. The mean implant size was 19 mm. There were no cases of implant extrusion or infection. All four had a <1 mm asymmetry in measured eyelid height and ≥5 mm horizontal gaze motility. All patients self-reported "good" cosmesis. An independent assessment identified "mild asymmetry" in two cases and "moderate" in the other two.

CONCLUSION

Evisceration with this novel autologous scleral graft technique restores volume in the anterior orbit with good cosmetic results, and with no cases of implant exposure reported in this small case series. This technique should be compared prospectively to established techniques.

The results of Muller Muscle Conjunctival Resection versus Levator Advancement for mild to moderate ptosis

Purpose: To compare the surgical outcomes of Muller muscle conjunctival resection (MMCR) and levator advancement (LA) in patients with mild to moderate blepharoptosis. Methods: A retrospective review of patients who underwent surgery for mild to moderate ptosis between 2015 and 2020 was performed. The degree of ptosis was graded based on the amount of upper eyelid drooping: mild ≤ 2 mm and moderate < 4 mm. Surgical success was defined as post-operative marginal reflex distance 1 (MRD1) ≥ 4.0 and ≤ 5.0 mm, and a satisfactory eyelid contour. Results: A total of 82 eyes of 65 patients underwent ptosis repair surgeries. MMCR was performed in 48 eyes and LA in 34 eyes. Under-correction was detected in 8.3% and 11.8% of the patients in MMCR group and LA group respectively. There was no patient with over-correction in the MMCR group postoperatively, 3 patients in the LA group had over-correction (0% vs. 8.8% respectively). The success rate in our study was found to be 91.7% in the MMCR group and 72.2% in the LA group. Conclusions: The MMCR and LA procedures are effective approaches in treating patients with mild to moderate eyelid ptosis in our population. Each procedure had its superiority in selected groups of patients. However, the complication rate and duration of surgery were found to be lower in MMCR group. Abbreviations: LA = Levator Advancement, LF = Levator Function, MMCR = Muller Muscle Conjunctival Resection, MRD 1 = Marginal Reflex Distance.

Validated Outcome Measures and Postsurgical Scar Assessment Instruments in Eyelid Surgery: A Systematic Review

BACKGROUND

Determining which postsurgical scar assessment instruments, if any, cover important eyelid outcome measures can either attest to the strength of one or more instruments or reveal the need for a more comprehensive scale.

OBJECTIVE

To systematically review validated outcome measures after eyelid surgery and postsurgical scar assessment tools to see whether any individual or combination of 2 assessment tools encompass all relevant, validated eyelid outcome measures.

METHODS

Systematic reviews of validated eyelid outcome measures and postsurgical scar assessment tools were conducted using PubMed/MEDLINE and Ovid. Outcome measure papers that met inclusion criteria were sorted into 8 categories: Patient Subjective, Visual Function, Mechanical Function, Daily Activities, Adverse Effects, Aesthetic Quantitative: Clinical Measurements, Aesthetic Qualitative: Global, and Aesthetic Qualitative: Specific. Outcome measure papers were categorized into tiers of evidence support, and assessment tools were evaluated based on which outcome measures each covered.

RESULTS

No one or combination of 2 assessment tools covered all selected eyelid outcome measures. Although measures related to the subjective patient experience were included in several of the assessment scales, none covered measures of visual function or eyelid-specific clinical measurements.

CONCLUSION

There is currently no existing postsurgical scar assessment instrument that covers all important eyelid-specific outcome measures.