Surgical outcomes of the anterior versus posterior approach for advancement of the levator aponeurosis in Japanese patients.

PURPOSE: To compare the surgical outcomes of the anterior and posterior approaches for advancement of the levator aponeurosis for aponeurotic blepharoptosis in relation to levator function (LF). METHODS: This retrospective study included 223 eyelids from 125 patients with aponeurotic blepharoptosis. The anterior approach was used for 115 eyelids from 65 patients (anterior group), while the posterior approach was used in 108 eyelids from 60 patients (posterior group). Patients were subdivided into two groups in accordance with their LF (fair: 5-10 mm; good: > 10 mm). Functional success was defined as a margin reflex distance of 2-5 mm without serious complications at 3 months postoperatively. Cosmetic success was defined as the achievement of ≤ 1 mm laterality of the upper eyelid height, ≤ 2 mm laterality of the pretarsal show, and eyelid contour symmetry at 3 months postoperatively. RESULTS: The functional success rates of the anterior and posterior groups were comparable for patients with good LF (78.9% vs 87.7%, p = 0.228), whereas it was better in the posterior group (85.7%) than the anterior group (64.1%) in the total group (p = 0.022) and in patients with fair LF (p = 0.031). The posterior group achieved better cosmetic success than the anterior group regarding upper eyelid height symmetry (p = 0.042) and pretarsal show (p = 0.012). No serious complications occurred during follow-up. CONCLUSIONS: The posterior approach achieved better functional and cosmetic outcomes than the anterior approach, indicating that the posterior approach is more useful in patients with aponeurotic blepharoptosis, particularly for those with only fair LF.

Influence of epinephrine contained in local anesthetics on upper eyelid height in transconjunctival blepharoptosis surgery.

PURPOSE: To examine the influence of epinephrine contained in local anesthetic on upper eyelid height in transconjunctival aponeurotic repair for aponeurotic blepharoptosis. METHODS: This retrospective study included 164 eyelids from 94 patients with aponeurotic blepharoptosis. Patients were divided according to the use of local anesthetic with (group A, n = 108) or without 1:100000 epinephrine (group B, n = 56). Margin reflex distance-1 (MRD-1) was measured before and after local anesthesia, and before, during, and 3 months after surgery. Change in MRD-1a (∆MRD-1a) was calculated by subtracting the postanesthetic MRD-1 value from the preanesthetic value, and we defined ∆MRD-1b by subtracting the postoperative 3-month MRD-1 value from the intraoperative value. RESULTS: ∆MRD-1a was positive in group A (0.57 ± 0.63 mm) and negative in group B (- 0.50 ± 0.45 mm; p < 0.001). Postoperative MRD-1 decreased significantly from intraoperative MRD-1 in group A (P < 0.001), although there was no significant difference between intraoperative and postoperative MRD-1 in group B (p = 0.255). The magnitude of ∆MRD-1b in group A (- 0.86 ± 0.63) was larger than that in group B (- 0.23 ± 0.26; p < 0.001). CONCLUSIONS: Epinephrine stimulates Müller's muscle during surgery, which leads to postoperative upper eyelid droop after the disappearance of the epinephrine effect. Using local anesthetics without epinephrine may allow more accurate estimation of postoperative eyelid height in transconjunctival aponeurotic repair.

Influence of fatty deposits in the levator aponeurosis/levator palpebrae superioris muscle on outcomes of aponeurotic repair in a Japanese population.

PURPOSE: To examine a part of the levator aponeurosis/levator palpebrae superioris (LPS) muscle that did not have fatty deposits in patients with aponeurotic blepharoptosis. We also analysed the relation between this length and surgical outcome after transcutaneous aponeurotic repair. METHODS: We measured the vertical length from the distal end of the anterior layer of the levator aponeurosis to the most distal point of fatty deposits in the levator aponeurosis/LPS muscle (non-fatty-deposit length) in 94 eyelids. Surgical success was defined as a postoperative margin reflex distance-1 (MRD-1) of 2.0-5.0 mm at 3 months postoperatively. The eyelids were classified into two groups: a surgical success group (group A, 76 eyelids) and an undercorrected group (group B, 18 eyelids). Group A was subdivided according to the evidence of a fatty deposit (group A1, fat present, 70 eyelids; group A2, fat absent, 6 eyelids). RESULTS: The non-fatty-deposit measurement was significantly longer in group A1 than in group B (p = 0.035). The levator aponeurosis was less advanced in groups A1 and A2 than in group B (both, p < 0.001), and the eyelids in groups A1 and A2 obtained a higher MRD-1 than those in group B (both, p < 0.001). CONCLUSIONS: Eyelids with less fat deposit required less advancement of the levator aponeurosis and obtained more favourable surgical results. Intraoperative findings of eyelids with and without fatty deposits and measuring the non-fatty-deposit length may be useful predictive parameters for outcomes of transcutaneous aponeurotic repair.

Recurrent Lower Eyelid Ectropion After Graft Surgery Using Autogenous Palmaris Longus Tendon.

A 78-year-old male experienced right lower eyelid ectropion following right facial trauma from a fall 5 years ago, for which he underwent autogenous palmaris longus tendon graft surgery at another clinic. Recurrence was noted 3 years after surgery. On first examination, there was outward turning of the lateral half of the right lower eyelid margin. We performed a lateral tarsal strip procedure with removal of the graft. Intraoperatively, the lateral part of the graft was located along the inferior tarsal border, whereas the medial part was located on the tarsal surface. The lateral stump had bifurcated; 1 branch had passed through a bony hole drilled at the base of the rim; and both branches had been ligated together on the rim surface. The medial side had been fixed to the medial canthal tendon. Postoperatively, the apposition of eyelid and ocular surface was good, and the patient experienced no recurrence after 1 year.

Transcutaneous aponeurotic repair with small detachment of the levator aponeurosis for aponeurotic blepharoptosis in Japanese patients.

PURPOSE: To examine the surgical outcomes of a modified transcutaneous aponeurotic repair for aponeurotic blepharoptosis in a Japanese population. METHODS: This retrospective study included 75 eyelids of 45 patients with aponeurotic blepharoptosis who had undergone a modified transcutaneous aponeurotic repair. This procedure included a long skin incision for securing a wide surgical field, creation of a double eyelid crease, and a small extent of detachment of the levator aponeurosis from the tarsal surface. Functional success was defined as a postoperative margin reflex distance-1 of 2-5 mm without serious complications at 3 months postoperatively. Cosmetic success was judged by achieving a ≤ 1-mm laterality of eyelid height, a ≤ 2-mm laterality of pretarsal show, and symmetry of the eyelid contour at 3 months postoperatively. RESULTS: The functional success rate was 70.7% among all patients, with 84.4%, 86.7%, and 88.9% of patients showing cosmetic success regarding symmetry of eyelid height, pretarsal show, and eyelid contour, respectively. After applying functional and all 3 cosmetic criteria simultaneously, 28 patients (62.2%) were satisfied in this study. No serious complications occurred during the follow-up period. CONCLUSIONS: This modified procedure provided good functional and cosmetic outcomes for aponeurotic blepharoptosis, indicating an acceptable blepharoptosis repair for East Asian patients.

Conjunctival Chemosis Caused by Exposure of the Lacrimal Caruncle: A Case Report.

An 84-year-old woman presented with a 3-month history of conjunctival chemosis in the left eye. At the first examination, the chemosis neighbored the lacrimal caruncle and was localized in the inferomedial region of the conjunctiva. During eyelid closure, only the left lacrimal caruncle was exposed. One month later, the chemosis further extended to the inferolateral region. We debulked the lacrimal caruncle to prevent the exposure of the caruncle. One month after the surgery, conjunctival chemosis had resolved completely. At the postoperative 6-month follow-up, the patient showed no recurrence of chemosis.

No Intense 18F-Fluorodeoxyglucose Uptake in Positron Emission Tomography of a Metastatic Orbital Tumor From Breast Carcinoma.

A 47-year-old woman with a history of invasive ductal carcinoma in the right breast reported decreased vision in the OD for the past 3 months. Her best corrected visual acuity was 0.1 OD and 1.0 OS. T1-weighted MRI revealed enlargement of the right lateral rectus muscle with a faint tumor outline and no contrast enhancement in the lesion. F-fluorodeoxyglucose positron emission tomography did not demonstrate intense uptake at the lesion. Because the patient demonstrated optic neuropathy due to compression by the enlarged muscle, balanced orbital decompression (of the deep lateral and medial orbital walls) was performed simultaneously with a tumor biopsy. Visual acuity of the OD was dramatically improved to 1.0. The histopathological examination demonstrated similar findings to her breast carcinoma. F-fluorodeoxyglucose positron emission tomography does not always show a positive result for an orbital tumor that has metastasized from the breast.

Combination of nasolabial v-y advancement flap and glabellar subcutaneous pedicled flap for reconstruction of medial canthal defect.

A 77-year-old woman presented with a 1-year history of a right medial canthal tumor, which was histopathologically diagnosed as a basal cell carcinoma. After removal of the tumor with a 4-mm safety margin, the defect occupied the areas superior and inferior to the medial canthal tendon. We first reconstructed the lower part of the defect using a nasolabial V-Y advancement flap to make an elliptic defect in the upper part. We then created a glabellar subcutaneous pedicled flap to match the residual upper elliptic defect with the major axis set along a relaxed skin tension line. The pedicled glabellar flap was passed through a subcutaneous tunnel to the upper residual defect. At 6 months postoperatively, the patient showed no tumor recurrence and a good cosmetic outcome.

A freely movable mucosa-associated lymphoid tissue lymphoma in the preaponeurotic space.

A 70-year-old man presented with a painless, solitary mass in the left upper eyelid. The mass moved freely in the whole upper eyelid. MRI revealed a 15×10×5 mm sized, well-circumscribed mass in the space between the orbital septum and the levator aponeurosis. The tumor was removed en bloc via a skin crease approach with simultaneous bilateral ptosis repair. The immunohistopathological diagnosis was a mucosa-associated lymphoid tissue (MALT) lymphoma. This is the first case of a freely movable MALT lymphoma in the preaponeurotic space.

Dacryoendoscopic findings of lacrimal passage with congenital punctal atresia.

A 43-year-old woman presented with epiphora caused by upper and lower congenital punctual atresia with papilla. She underwent 2-snip punctoplasty and intubation under local anaesthesia. During the surgery, a dacryoendoscopic examination was performed. After performing the punctoplasty, the lacrimal passage was confirmed to have complete canalisation to the nasal cavity. Both upper and lower canaliculi appeared to be narrower and had difficult expansion compared with canaliculi in congenital nasolacrimal duct obstruction or primary acquired nasolacrimal duct obstruction without canalicular stenosis. The lacrimal sac and the nasolacrimal duct also showed complete canalization with normal colour.

Anatomy of secretory glands in the eyelid and conjunctiva: a photographic review.

The eyelid and conjunctiva are main targets in ophthalmic plastic surgery. Although dry eyes are known to occasionally occur after ophthalmic plastic surgery, little attention has been paid to the secretory glands in the eyelid and conjunctiva. The secretary glands in the eyelid and conjunctiva contain the main lacrimal gland, accessory lacrimal glands of Wolfring and Krause, goblet cells, ciliary glands of Moll and Zeis, and the meibomian gland of the tarsal plate. Understanding the details of these glands is helpful in preventing and managing secretion reduction after oculoplastic procedures.