The Effect of Conjunctiva-Müller Muscle Resection on Tear Oxidative Stress Levels in Patients with Blepharoptosis

Objectives: To examine changes in tear oxidative stress levels and tear film functions in patients with blepharoptosis and dermatochalasis following conjunctiva-Müller muscle resection (CMMR) and blepharoplasty surgeries. Materials and Methods: This prospective study included 32 healthy controls and 62 patients with blepharoptosis or dermatochalasis. CMMR surgery was performed in 20 eyes and upper blepharoplasty was performed in 42 eyes. Tear oxidative stress markers (8-hydroxy-2'-deoxyguanosine [8-OHdG] and 4-hydroxy-2-nonenal [4-HNE]) were quantified by enzyme-linked immunosorbent assay and tear film functions were evaluated preoperatively and at 1 and 6 months postoperatively. The same assessments were performed in the control group at the same time points. Results: Preoperative tear 8-OHdG and 4-HNE levels were lower in healthy controls (52.8±13.5 ng/mL and 27.8±6.4 ng/mL, respectively) compared to patients with dermatochalasis (86.1±37.2 ng/mL and 29.8±11.1 ng/mL, respectively) and blepharoptosis (90.4±39.3 ng/mL and 43.1±4.2 ng/mL, respectively) (p<0.001). 8-OHdG levels were increased at 1 month after CMMR, while both markers were decreased 1 month postoperatively in the blepharoplasty group (p=0.034). Schirmer 1 and OSDI scores did not change throughout the visits in both patient groups, but a temporary decrease in tear break-up time (TBUT) was observed after CMMR (p=0.017). Conclusion: Dermatochalasis and blepharoptosis were associated with higher tear oxidative stress levels. CMMR surgery caused a temporary decrease in TBUT scores and an increase in oxidative stress in the first postoperative month.

The Type and Content of Collagen Fibers of the Levator Aponeurosis in Patients With Simple Congenital Blepharoptosis.

BACKGROUND: The pathogenesis of congenital blepharoptosis remains controversial and most of the studies focused on the histologic changes of the levator muscle. However, thickening of the aponeurosis was reported in congenital blepharoptosis. And the thickness of the levator aponeurosis was found to be correlated with the levator function in congenital dysmyogenic blepharoptosis. PURPOSE: The authors conducted this research to investigate the histological changes of the levator aponeurosis of simple congenital blepharoptosis patients. PATIENTS AND METHODS: The authors analyzed 12 levator aponeurosis from ptosis patients and 21 levator aponeurosis from the cadaver specimens without relative medical history. The specimens were stained with hematoxylin and eosin as well as Sirius red. The sections were examined under light-microscopy. The content and type of collagen fibers were examined with the photos taken of the sections stained with Sirius red under polarized light-microscopy. RESULTS: The content and proportion of type I collagen increased significantly in the patient group compared with the cadaver group. The proportion of type I collagen was 97.5% in the patient group, while it was 51.5% in the cadaver group. However, no correlation was found either between the levator strength, degree of ptosis and the proportion of type I collagen in the patient group or between age, gender and proportion of type I collagen in the cadaver group. CONCLUSIONS: To our knowledge, this is the first time this phenomenon was discovered. The increase of type I collagen in the levator aponeurosis of the simple congenital blepharoptosis patients may imply the increased stiffness and undermined ability of transmitting forces, dissipate energy and prevent mechanical failure in the levator aponeurosis.

Changes in Tear Meniscus Height Following Lower Blepharoplasty as Measured by Optical Coherence Tomography.

PURPOSE: The lower eyelid serves important roles in tear distribution and drainage. The purpose of this study was to measure the tear meniscus height (TMH) with anterior segment optical coherence tomography after lower blepharoplasty. METHODS: A total of 52 eyes from 26 patients treated between July 2012 and June 2015 were included in the study. A transcutaneous or transconjunctival approach was performed, depending on whether (1) the supportive lower lid orbicularis oculi muscle was tightened, (2) the middle lamella was elongated, (3) minimal fat was removed or transpositioned, and (4) lateral canthal support was established. Marginal reflex distance 2 and marginal nose distance were analyzed with Image J software. TMH was measured with anterior segment optical coherence tomography. A paired t-test and Wilcoxon signed-rank test were used for statistical comparisons. RESULTS: Marginal reflex distance 2 decreased and marginal nose distance increased with both surgical techniques. TMH decreased from 337.3 ± 117.9 to 289.3 ± 69.1 µm (p = 0.024) in patients who had transcutaneous lower blepharoplasty, but increased from 186.5 ± 35.5 to 274.8 ± 58.3 µm (p = 0.000) in patients who had transconjunctival lower blepharoplasty. Medial and lateral TMHs decreased significantly from 228.8 ± 80.7 to 152.7 ± 42.1 µm (p = 0.008) in patients with transcutaneous lower blepharoplasty. TMH was significantly restored after lower blepharoplasty with either approach. CONCLUSIONS: Enhancing the lower eyelid position combined with orbicularis muscle tightening and lateral canthal support can normalize the TMH following lower eyelid blepharoplasty.

Amblyopia, Strabismus and Refractive Errors in Congenital Ptosis: a systematic review and meta-analysis.

Congenital ptosis may be associated with abnormalities of visual development and function, including amblyopia, strabismus and refractive errors. However, the prevalence estimates of these abnormalities vary widely. We performed a systematic review and meta-analysis to estimate the prevalence of amblyopia, strabismus and refractive errors in congenital ptosis. Cochrane, Pubmed, Medline, Embase, and Web of Science were searched by July 2017. We used random/fixed effects models based on a proportion approach to estimate the prevalence. Heterogeneity would be considered signifcant if the p values less than 0.1 and/or I2 greater than 50%. Subgroup analyses, meta-regression analyses and sensitivity analyses were utilized to explore the potential sources of it. A total of 24 studies selected from 3,633 references were included. The highest prevalence was revealed for myopia with 30.2% (95%CI 3.0-69.8%), followed by 22.7% (95%CI 18.5-27.8%) for amblyopia, 22.2% (95%CI 7.8-63.1%) for astigmatism, 19.6% (95%CI 16.5-23.2%) for strabismus, 17.3% (95% CI 13.1-22.9%) for anisometropia and 4.0% for hyperopia (95%CI 1.8-7.1%). Significant heterogeneity was identified across most estimates. Our findings suggest that amblyopia, strabismus and refractive errors in congenital ptosis are present in much higher percentage. This study highlights the importance of early diagnosis and timely treatment of patients with congenital ptosis.

l-3,4-Dihydroxyphenylalanine induces ptosis through a GPR143-independent mechanism in mice.

Through its conversion to dopamine by aromatic l-amino acid decarboxylase (AADC), l-3,4-dihydroxyphenylalanine (l-DOPA) replenishes depleted brain dopamine in Parkinson's disease patients. We recently identified GPR143 as a candidate receptor for l-DOPA. In this study, we investigated the behavioral actions of l-DOPA in wild type (wt) and Gpr143-deficient mice. l-DOPA dose-dependently (10-100 mg/kg, i.p.) induced ptosis under treatment with 3-hydroxybenzylhydrazine, a centrally acting AADC inhibitor. This effect was not mimicked by 3-O-methyldopa. l-DOPA-induced ptosis in Gpr143-deficient mice to a similar extent as in wt mice. These results suggest that l-DOPA induces ptosis in a GPR143-independent fashion in mice.

Long-term tear volume changes after blepharoptosis surgery and blepharoplasty.

PURPOSE: To evaluate long-term changes in tear volume by using video meniscometry following blepharoptosis surgery and upper blepharoplasty. METHODS: Forty-three eyes of 27 patients with blepharoptosis and 29 eyes of 18 patients with dermatochalasis without lacrimal duct obstruction or other eyelid diseases underwent anterior approach levator advancement or blepharoplasty. Tear volume was evaluated by measurement of tear meniscus radius (R), using video meniscometry preoperatively and at 1.5, 3, and 6 months postoperatively. Margin reflex distance-1 (MRD-1) was measured before and after surgery by using photographs. RESULTS: After blepharoptosis surgery, the mean MRD-1 was significantly increased: 0.45 mm preoperatively, 3.64 mm at 1.5 months, 3.56 mm at 3 months, and 3.57 at 6 months postoperatively (P < 0.001), and the average R value was significantly decreased: 0.29 mm preoperatively, 0.22 mm at 1.5 months, 0.23 mm at 3months, and 0.24 mm at 6 months postoperatively (P < 0.05). Preoperative R was significantly correlated to the reduction rate of R (ΔR). A higher preoperative R was more likely to be decreased (P < 0.01). Postoperative MRD-1 and change in MRD-1 were not correlated to ΔR. After blepharoplasty, the preoperative mean MRD-1 (3.11 mm) was significantly decreased at 1.5 months (2.47 mm; P < 0.01) and 3 months (2.71 mm; P < 0.05) but recovered at 6 months (3.14 mm). However, the average R was not changed: 0.31 mm preoperatively, 0.34 mm at 1.5 months, 0.31 mm at 3 months, and 0.33 mm at 6 months postoperatively. CONCLUSIONS: Long-term tear volume was not changed after blepharoplasty but was decreased after blepharoptosis surgery, and even more so in cases with an initial high tear volume.

Oxidative stress in the levator aponeurosis in Asian involutional blepharoptosis.

PURPOSE: To analyze the histopathology and expression of 8-hydroxydeoxyguanosine (OHdG), a marker of oxidative stress, in the levator aponeurosis tissues of involutional aponeurotic and congenital blepharoptosis patients, and adult subjects with no history of blepharoptosis. METHODS: Fourteen and 4 levator aponeurosis tissues obtained from Asian patients with involutional and congenital blepharoptosis and 3 normal adult tissues were examined. All tissues were fixed in 4% paraformaldehyde, embedded in paraffin, and then submitted for hematoxylin and eosin staining and immunohistochemistry with anti-8-OHdG antibody. RESULTS: The levator aponeurosis tissues contained spindle smooth muscle fibers and striated muscles. Nuclear immunoreactivity for 8-OHdG was noted in striated and smooth muscle cells in all the tissues. The 8-OHdG-positive rate was significantly lower in congenital blepharoptosis than involutional blepharoptosis (p < 0.05). Moreover, the number of 8-OHdG-positive striated muscle cells was significantly higher in the involutional blepharoptosis than normal tissues (p < 0.05). In contrast, there was a rare positive 8-OHdG-immunoreactivity of smooth muscle cells in the aponeurotic tissues of the involutional blepharoptosis patients. CONCLUSIONS: Levator aponeurosis in involutional aponeurotic blepharoptosis tissues showed oxidative stress in the muscle, indicating that oxidative stress plays a potential role in the pathologic study of the disease.

Short-term changes in tear volume after blepharoptosis repair.

PURPOSE: The aim was to evaluate tear volume change by using videomeniscometry before and after blepharoptosis surgery. METHODS: Fifty-nine eyes of 36 patients with blepharoptosis without lacrimal duct obstruction or other eyelid diseases were examined. All the patients underwent levator advancement, and the tear volume was evaluated preoperatively and 1.5 months postoperatively. The margin reflex distance-1 was determined from photographs, and the tear volume was determined by the measurement of tear meniscus radius using videomeniscometry. RESULTS: The mean margin reflex distance-1 was significantly increased after performing a blepharoptosis surgery (0.13 ± 1.13 mm preoperatively vs. 3.18 ± 0.85 mm postoperatively, P < 0.001). The average tear meniscus radius was significantly decreased (0.31 ± 0.16 mm preoperatively vs. 0.23 ± 0.08 mm postoperatively, P < 0.001). A postoperative reduction in the tear meniscus radius was noted in 46 eyes (78%) of 31 patients, and no reduction was noted in 13 eyes (22%) of 12 patients. Preoperative higher tear meniscus radius values were more likely to be decreased (P < 0.01). CONCLUSIONS: The tear volume was decreased after the blepharoptosis surgery was performed, especially for an initially high tear volume.

Alpha(1A)-adrenergic control of piloerection and palpebral fissure width in rats.

We determined the receptor subtypes of α1-adrenoceptor, which is involved in autonomic functions induced by methamphetamine (METH) in rats. An intraperitoneal injection of METH provoked the autonomic responses piloerection, eyelid retraction, and ejaculation. Pretreatment with prazosin, a nonselective α1-adrenoceptor antagonist, completely abolished the above METH-induced responses. Prazosin also provoked eyelid ptosis in saline controls. The effects of prazosin were mimicked only by a selective α1A-adrenoceptor antagonist, silodosin, not by selective α1B or α1D antagonists. These results suggest that α1A-adrenoceptor participates in the regulation of piloerection, palpebral fissure width, and ejaculation in rats.

Ptosis and ophthalmoplegia associated with epidermolysis bullosa simplex-muscular dystrophy.

The association of epidermolysis bullosa simplex and muscular dystrophy (EBS-MD) has rarely been discussed in ophthalmology literature. This case report offers a brief summary of epidermolysis bullosa and describes what is known about EBS-MD. The case involves a patient with EBS-MD who presented with ptosis and ophthalmoplegia, suggesting that these may be complications of EBS-MD.

Clinical and histologic ocular findings in pompe disease.

PURPOSE: Limited information is available on the ocular findings in patients with Pompe disease. METHOD: This study summarizes this information with a systematic literature review; reports the ocular histologic findings seen in a deceased infant with Pompe disease who was receiving enzyme replacement therapy and in a deceased adult with late-onset Pompe disease; and notes the new observation of ptosis in children with infantile-onset Pompe disease who are receiving enzyme replacement therapy. RESULTS: Six articles were found on the ultrastructural-histopathologic eye findings in Pompe disease. Previously reported clinical ocular findings included strabismus and ptosis. Glycogen accumulation and vacuolar myopathy have been seen histologically. CONCLUSION: Based on these clinical and histologic reports, patients with Pompe disease may have an increased incidence of ocular abnormalities, such as ptosis and strabismus, and therefore should undergo ophthalmologic examination.

A major mutation of KIF21A associated with congenital fibrosis of the extraocular muscles type 1 (CFEOM1) enhances translocation of Kank1 to the membrane.

Congenital fibrosis of the extraocular muscles type 1 (CFEOM1) is associated with heterozygous mutations in the KIF21A gene, including a major (R954W) and a minor (M947T) mutation. Kank1, which regulates actin polymerization, cell migration and neurite outgrowth, interacted with the third and fourth coiled-coil domains of KIF21A protein at its ankyrin-repeat domain. While both KIF21A(R954W) and KIF21A(M947T) enhanced the formation of a heterodimer with the wild type, KIF21A(WT), these mutants also enhanced the interaction with Kank1. Knockdown of KIF21A resulted in Kank1 predominantly occurring in the cytosolic fraction, while KIF21A(WT) slightly enhanced the translocation of Kank1 to the membrane fraction. Moreover, KIF21A(R954W) significantly enhanced the translocation of Kank1 to the membrane fraction. These results suggest that KIF21A regulates the distribution of Kank1 and that KIF21A mutations associated with CFEOM1 enhanced the accumulation of Kank1 in the membrane fraction. This might cause an abrogation of neuronal development in cases of CFEOM1 through over-regulation of actin polymerization by Kank1.

Glucose metabolism in the idiopathic blepharoptosis: utility of the Oral Glucose Tolerance Test (OGTT) and of the Insulin Resistance Index.

BACKGROUND: Diabetes mellitus (DM), neuromuscular, hereditary or immunological disorders are the most common identified causes of blepharoptosis. However, in about 15-25% they remained uncertain. OBJECTIVE: To determined the role of glucose metabolism abnormality in idiopathic blepharoptosis. METHODS: We identified 162 patients with unilateral idiopathic blepharoptosis and 128 control subjects. In all we evaluated a glucose and insulin levels at fasting and after 2 h-OGTT. In addition we determined insulin resistance (IR), by HOMA-index. RESULTS: Following a 2 h-OGTT the prevalence of undiagnosed glucose metabolism abnormality was significantly higher in blepharoptosis patients vs. control group (P<.001). The IR was documented in 129 patients (78%), of whom 55 (34%) had Impaired Glucose Tolerance (IGT), 36 (22%) newly diagnosed DM (NDDM) and 38 (30%) only IR. The Body Mass Index, blood pressure, serum lipids, triglycerides and smoking were not associated with an increased risk of developing ptosis. Conversely, waist circumference were significantly increased in blepharoptosis patients (P=.003). CONCLUSIONS: In this study we focused on emerging evidence that prediabetic status may represent a risk factor for developing blepharoptosis. We propose that 2 h-OGTT and mainly HOMA-index should be determined as a rule in all patients with idiopathic blepharoptosis.

FoxL2 and Smad3 coordinately regulate follistatin gene transcription.

Follistatin is a transcriptional target and a modulator of activin action. Through an autocrine/paracrine loop, activin controls follistatin levels and thus regulates its own bioavailability. In gonadotropic alphaT3-1 cells, activin induces follistatin transcription primarily through the action of Smad3 at an intronic Smad-binding element (SBE1). Using a proteomics approach, we searched for endogenous alphaT3-1 proteins that participate in SBE1-mediated transcription. We identified FoxL2, a member of the forkhead family, as a candidate modulator of SBE1 function. Mutations of FoxL2 are associated with the blepharophimosis/ptosis/epicanthus inversus syndrome characterized with craniofacial defects and premature ovarian failure. FoxL2 localizes to alpha-glycoprotein subunit- and follicle-stimulating hormone beta-positive cells of the adult mouse pituitary and is present in alphaT3-1 and LbetaT2 cells, but its pituitary actions remain largely unknown. We have determined that FoxL2 binds to a forkhead-binding element (FKHB) located just downstream of the SBE1 site of the follistatin gene and functions as a Smad3 partner to drive SBE1-mediated transcription in alphaT3-1 cells treated with activin. Chromatin immunoprecipitation assays confirm that endogenous FoxL2 and Smad3 are recruited to the intronic enhancer of the follistatin gene where the SBE1 and FKHB sites are located. Exogenous FoxL2 enhances SBE1-mediated transcription, and short hairpin RNA-mediated knockdown of endogenous FoxL2 protein compromises this effect in alphaT3-1 cells. FoxL2 directly associates with Smad3 but not Smad2 or Smad4. This association between Smad3 and FoxL2 is mediated by the MH2 domain of Smad3 and is dependent on an intact forkhead domain in FoxL2. Altogether, these observations highlight a novel role for FoxL2 and suggest that it may function as a transcriptional regulator and a coordinator of Smad3 targets.

Adrenergic receptors in the ptotic human eyelid: correlation with phenylephrine testing and surgical success in ptosis repair.

PURPOSE: To investigate the relationship between adrenergic receptors in Müller muscle and response to phenylephrine testing in patients undergoing ptosis surgery. This study also compares outcomes of Fasanella and Putterman approaches to posterior ptosis repair. METHODS: Prospective analysis of 71 patients undergoing posterior ptosis surgery. Eyelid height was measured before and after phenylephrine. Müller muscle was examined for alpha-1D, alpha-2C, beta-1, and beta-2 receptors. Specimens were graded on receptor staining intensity. Patients were seen 1 week and 6 weeks following surgery. Surgical outcomes were scored on a scale of 1 (most favorable) to 3 (least favorable). RESULTS: Adrenergic receptors were found in decreasing order: alpha-1D, beta-1, alpha-2C, and beta-2. Receptor grade significantly predicted eyelid height for alpha-2C receptors (p = .03). Mean outcome scores for 36 Putterman (1.10) and 35 Fasanella (1.27) procedures were not significantly different. CONCLUSIONS: Alpha 1D, alpha-2C, and beta-2 receptors are documented within human Müller muscle. Human eyelid elevation response to phenylephrine is inversely related to the amount of alpha-2C receptor staining in Müller muscle. Fasanella and Putterman procedures have equal outcomes, independent of adrenergic receptors.

Foxl2 function in ovarian development.

Foxl2 is a forkhead transcription factor essential for proper reproductive function in females. Human patients carrying mutations in the FOXL2 gene display blepharophimosis/ptosis/epicanthus inversus syndrome (BPES), an autosomal dominant disease associated with eyelid defects and premature ovarian failure in females. Recently, animal models for BPES have been developed that in combination with a catalogue of human FOXL2 mutations provide further insight into its molecular function. Mice homozygous mutant for Foxl2 display craniofacial malformations and female infertility. The analysis of the murine phenotype has revealed that Foxl2 is required for granulosa cell function. These ovarian somatic cells surround and nourish the oocyte and play an important role in follicle formation and activation. Mutations upstream of FOXL2 in humans, not affecting the coding sequence itself, have also been shown to cause BPES, which points to the existence of a distant regulatory element necessary for proper gene expression. The same regulatory sequences may be deleted in the goat polled intersex syndrome (PIS), in which FoxL2 expression is severely reduced. Sequence comparison of FoxL2 from several vertebrate species has shown that it is a highly conserved gene involved in ovary development. Thus, the detailed understanding of Foxl2 function and regulation and the identification of its transcriptional targets may open new avenues for the treatment of female infertility in the future.