Eyelid surgery in ocular myopathies

OBJECTIVE

To retrospectively analyse surgical outcome and complications in patients with ocular myopathy undergoing ptosis correction and to introduce preoperative prophylactic lower lid elevation in this group.

METHODS

The medical records of all ocular myopathy patients who had undergone oculoplastic surgery between June 1995 and May 2006 were obtained. Patients' demographics, surgical details and measurements, and complications were recorded.

RESULTS

29 patients were identified; 21 with chronic progressive external ophthalmoplegia (CPEO), 7 with myotonic dystrophy (MD) and 1 with oculopharyngeal muscular dystrophy (OPMD). Then, 61 procedures to adjust eyelid height were performed, comprising levator resection, brow suspension, anterior lamellar repositioning, lower lid elevation and upper lid lowering. Palpebral aperture was significantly increased in all patient groups, by procedure and diagnosis, more significantly following brow suspension compared with levator resection. The patients' feedback was very positive. Post-operative complications were few, included corneal exposure and ulceration, ptosis recurrence, arched brow, and sling infection, all of which were successfully treated.

CONCLUSION

Our results demonstrate subjective and objective benefit following surgery in these patients, with a low complication rate. The use of pre-operative prophylactic lower lid elevation procedures is a promising modality.

Postoperative complications in patients with oculopharyngeal muscular dystrophy: a retrospective study

PURPOSE

Oculopharyngeal muscular dystrophy (OPMD) is a genetic disease with autosomal dominant transmission particularly common in Quebec where its prevalence is about 1:1000. The main features are bilateral ptosis of the eyelids and dysphagia. These symptoms are frequently treated surgically by levator palpebrae resection (LPR) and cricopharyngeal myotomy (CPM). The objectives of this retrospective chart review were to describe the postoperative complications in OPMD patients undergoing LPR or CPM and to determine their incidence.

METHODS

Medical records of all OPMD patients who had either LPR or CPM between 1997 and 2002 were reviewed. The following complications were collected: death, pneumonia, aspiration pneumonitis, airway obstruction, reintubation, and severe coughing and choking caused by profuse secretions.

RESULTS

One hundred and fourteen surgeries on 92 OPMD patients were studied. Fifty-nine were LPR under general anesthesia (LPR-GA) and 22 were LPR under local anesthesia (LPR-LA). Thirty-three surgeries were CPM, all under general anesthesia. There was no death or reintubation. Patients who had LPR-LA had shorter postanesthesia care unit (P<0.001) and ambulatory surgery unit (P<0.001) stays than those who had LPR-GA. Complications were more frequent after CPM than LPR-GA (P<0.001).

CONCLUSION

The complication rate after LPR was low. Both local and general anesthesia are safe alternatives in OPMD patients operated for LPR. Patients having CPM presented more respiratory complications than those having LPR.

Risk factors in patients undergoing cricopharyngeal myotomy

Background

Cricopharyngeal myotomy for oropharyngeal dysphagia is designed to improve symptoms, but the operation can result in significant morbidity and even death.

Methods

A retrospective analysis was carried out of all complications and deaths among 253 patients who had cricopharyngeal myotomy performed by a single surgeon.

Results

A single wound infection developed among 15 patients with neurological dysphagia. The same patient subsequently required laryngeal exclusion and tracheostomy. Of 139 patients treated for dysphagia secondary to muscular dystrophy, haematoma formation or infection occurred in four, and eight patients developed postoperative pulmonary complications, four of whom died from respiratory distress syndrome. Two patients with myogenic dysphagia required laryngeal exclusion with a permanent tracheostomy. Infection of the wound or retropharyngeal space was the main problem in 90 patients with a pharyngo-oesophageal diverticulum, affecting 9 per cent of the patients. Fistula was documented in three patients overall (1·2 per cent). Systemic morbidity unrelated to the technique occurred in 26 patients (10·3 per cent).

Conclusion

Pulmonary aspiration and lethal respiratory distress occurred only in patients with myogenic dysphagia. Local infection was the main complication in those with pharyngo-oesophageal diverticulum. Persistent aspiration can lead to laryngeal exclusion or resection with permanent tracheostomy.

Reconstructive rhytidectomy?

Muscular dystrophies are commonly considered hereditary progressive degenerative diseases that affect skeletal and cardiac muscles. Oculopharyngeal muscular dystrophy is a rare hereditary disorder of later onset consisting of progressive dysphagia and bilateral blepharoptosis unlike the peripheral muscular weakness common to other muscular dystrophies. The symptoms of progressive dysphagia, with bilateral ptosis, usually occur after the age of 40 years. The authors present a patient with oculopharyngeal muscular dystrophy and chronic facial pain relieved by midface soft tissue support, namely, the reconstructive rhytidectomy.

Long-term results of cricopharyngeal myotomy in oculopharyngeal muscular dystrophy

OBJECTIVE

To analyze long-term results of extramucosal cricopharyngeal myotomy in oculopharyngeal muscular dystrophy.

STUDY DESIGN

The preoperative and postoperative evaluations including symptoms, type of feeding, weight, and functional examinations were retrospectively evaluated in 39 patients. Results were defined postoperatively as successful, partial, or failed.

SETTING

University hospital.

RESULTS

In the short term, 25 patients showed a complete remission of symptoms, 10 showed a marked improvement, and 4 exhibited no improvement at all (success rate of 90%). Long-term evaluation during a mean follow-up of 4 years showed that of the 35 improved patients, 12 exhibited a recurrence of dysphagia (mean time of 39 months). In 3 of these 12 patients, a revision transmucosal endoscopic cricopharyngeal myotomy was performed with a successful outcome in 2. Of the 4 patients who initially showed no improvement, 1 was improved by transmucosal myotomy.

CONCLUSION

Extramucosal cricopharyngeal myotomy improves dysphagia in oculopharyngeal muscular dystrophy patients during the first few years but one third of the patients exhibited a recurrence of symptoms within 3 years. Revision by transmucosal endoscopic myotomy may be performed.

EBM RATING

C-4.

Myoblast transfer therapy: is there any light at the end of the tunnel?

Myoblast transfer therapy (MTT) was proposed in the 70's as a potential treatment for muscular dystrophies, based upon the early results obtained in mdx mice: dystrophin expression was restored in this model by intramuscular injections of normal myoblasts. These results were quickly followed by clinical trials for patients suffering from Duchenne Muscular Dystrophy (DMD) in the early 90's, based mainly upon intramuscular injections of allogenic myoblasts. The clinical benefits obtained from these trials were minimal, if any, and research programs concentrated then on the various pitfalls that hampered these clinical trials, leading to numerous failures. Several causes for these failures were identified in mouse models, including a massive cell death of myoblasts following their injection, adverse events involving the immune system and requiring immunosuppression and the adverse events linked to it, as well as a poor dispersion of the injected cells following their injection. It should be noted that these studies were conducted in mouse models, not taking into account the fundamental differences between mice and men. One of these differences concerns the regulation of proliferation, which is strictly limited by proliferative senescence in humans. Although this list is certainly not exhaustive, new therapeutic venues were then explored, such as the use of stem cells with myogenic potential, which have been described in various populations, including bone marrow, circulating blood or muscle itself. These stem cells presented the main advantage to be available and not exhausted by the numerous cycles of degeneration/regeneration which characterize muscle dystrophies. However, the different stem candidates have shown their limits in terms of efficiency to participate to the regeneration of the host. Another issue was raised by clinical trials involving the injection of autologous myoblasts in infacted hearts, which showed that limited targets could be aimed with autologous myoblasts, as long as enough spared muscle was available. This resulted in a clinical trial for the pharyngeal muscles of patients suffering from Oculo-Pharyngeal Muscular Dystrophy (OPMD). The results of this trial will not be available before 2 years, and a similar procedure is being studied for Fascio-Scapulo-Humeral muscular Dystrophy (FSHD). Concerning muscular dystrophies which leave very few muscles spared, such as DMD, other solutions must be found, which could include exon-skipping for the eligible patients, or even cell therapy using stem cells if some cell candidates with enough efficiency can be found. Recent results concerning mesoangioblasts or circulating AC133+ cells raise some reasonable hope, but still need further confirmations, since we have learned from the past to be cautious concerning a transfer of results from mice to humans.

Quality of life following surgical treatment of oculopharyngeal syndrome

Oculopharyngeal syndrome is a hereditary disease mostly affecting French Canadians. Cricopharyngeal myotomy and blepharoplasty are commonly performed on these patients. We reviewed the files of 20 patients who underwent these procedures between June 1986 and June 1999. The average perioperative stay was 4.7 days. The nine patients still alive were contacted and answered a telephone survey on their quality of life. None reported postoperative complications. Myotomy significantly improved the medical domain of their quality of life as confirmed by improvement in the dysphagia for solids, food incarceration, duration of meals, and choking during meals. The psychological domain also improved, namely, appetite and interest in food. The effects of blepharoplasty were also notable. Long-term satisfaction is reported by the majority of patients up to a maximum of 10 years postoperatively. In conclusion, simple procedures such as blepharoplasty and cricopharyngeal myotomy greatly improved the quality of life of these patients. We therefore recommend early interventions.