Topical Review: An Update of Diagnostic and Management Algorithms for Acquired Blepharoptosis.

SIGNIFICANCE: Acquired ptosis is a condition of the upper eyelid that has negative cosmetic and functional effects but is likely underdiagnosed and undertreated. Given the evolving understanding of the condition and expanding therapeutic options, this review reappraised published evidence and clinical experience regarding diagnosis and treatment of acquired ptosis.The authors met over two structured virtual working sessions to review current evidence and develop timely recommendations for acquired ptosis identification, differential diagnosis, characterization, and treatment selection. Diagnostic algorithms, plus management and referral guidelines, are presented. Eyelid evaluation and, when needed, ptosis diagnostic workup are essential in the comprehensive eye examination. Acquired ptosis can be efficiently identified via patient questionnaire, history, and photograph review combined with assessment of eyelid position and symmetry using established methods. When ptosis is present, it is essential to evaluate onset, symptoms, pupil diameter, and extraocular muscle function to identify or rule out serious underlying conditions. If signs of serious underlying etiology are present, immediate referral/follow-up testing is required. After ruling out serious underlying causes, masquerade conditions, and pseudoptosis, pharmacologic or surgical treatment should be selected based on the clinical evidence. Effectively managing acquired ptosis requires practice-wide commitment to thorough eyelid evaluation, accurate diagnosis, and adoption of new treatment modalities. Aided by evolving pharmacologic therapeutic options, shifting from a "detect and refer" to a "diagnose and manage" approach can support identification and treatment of more patients with acquired ptosis, particularly mild-to-moderate cases.

3D printing for low cost, rapid prototyping of eyelid crutches.

Blepharoptosis or ptosis is a common and potentially debilitating clinical problem. Long-term surgical treatment for ptosis caused by progressive myopathies can be challenging due to potential recurrence and complications associated with facial muscle weakness. When surgical treatment is no longer effective, an eyelid crutch can be used as an alternative intervention. This report demonstrates how 3D printing was used to rapidly design, prototype, and manufacture new custom-fit eyelid crutches at a low cost.

Ocular ptosis: differential diagnosis and treatment.

PURPOSE OF REVIEW: The current article provides a brief summary of the clinical approach to congenital and acquired ptosis. An increasing number of publications analyze causes of ptosis or describe diagnostic tests or advances in ptosis genetics. The aim of our work is to summarize these findings and provide an updated algorithm for the diagnosis and treatment of patients with ptosis. This review covers important clinical research and studies relevant for neurologists recently published. RECENT FINDINGS: Ptosis is a common cause of referral to neuromuscular units. Knowledge of the different causes of this symptom has grown substantially in recent years, from diagnostic tests and genetics studies to potential new therapeutic agents, making it essential to keep up to date on the diagnostic and therapeutic relevance of these contributions. SUMMARY: We emphasize that ptosis should be studied as a complex symptom. Efforts should be made to identify accompanying neurologic or ophthalmologic signs in clinical examination that could lead to a diagnosis. A growing number of diagnostics tests are available in the field, especially in genetics. Meanwhile, surgery continues being the most used therapeutic approach for these patients.

Utility of PROSE Device in the Management of Complex Oculoplastic Pathology.

PURPOSE: To describe the use of Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) device in the management of complex oculoplastic pathology. METHODS: The authors retrospectively reviewed the records of individuals over 18 years of age who were referred and successfully fit with the PROSE scleral device between January 1995 and June 2015. RESULTS: Nine cases were identified that had complex oculoplastic disease and severe corneal surface disease. All patients with ptosis had improvement in marginal reflex distance-1 following PROSE and 5 of 7 patients with ptosis were spared further surgical intervention. Two underwent surgical repair with successful corneal stabilization with PROSE. Those with eyelid malposition including ectropion, entropion, or trichiasis experienced improvement in their corneal surface and deferred further surgical intervention. CONCLUSIONS: These cases highlight the use of the PROSE device to elevate the upper eyelid in patients with lagophthalmos and ptosis, stabilize the corneal surface to allow for additional eyelid surgery to be performed safely, and protect the corneal surface in patients with intractable trichiasis and entropion. Prosthetic Replacement of the Ocular Surface Ecosystem should be considered in patients with complex oculoplastic pathology to improve visual function, corneal surface disease, and eyelid position.

[Botulinum Toxin - New Developments in Ophthalmology]. / Botulinumtoxintherapie ­ neue Entwicklungen in der Augenheilkunde.

Botulinum toxin is recognised as the gold standard for the treatment of essential blepharospasm and hemifacial spasm, which is similar in effect in synkinesis after facial nerve palsy. The injection intervals can be adjusted according to the patients' needs and be shortened for up to six weeks in cases of eyelid cramping. Newer indications for the use of botulinum toxin in ophthalmology include eyelid retraction in Graves' disease, induction of protective ptosis and treatment of crocodile tears syndrome after facial nerve palsy. In future, botulinum toxin may be used in depression (facial feedback), facial injuries and for protection of facial glands against irradiation injury.

[Chronic Progressive External Ophthalmoplegia Ptosis: Problems with Diagnostics and Treatment]. / Ptosis bei chronisch progressiver externer Ophthalmoplegie: diagnostische Probleme und therapeutische Konsequenzen.

Ptosis is often the first symptom of chronic progressive external ophthalmoplegia (CPEO), a rare muscle disorder. As the disease progresses, it can lead to ocular motility defects. Ptosis is present in the early stages of the disease and can be corrected by levator surgery. Due to the rarity of CPEO (< 1% of ptosis patients), further diagnostic steps with muscle biopsy and genetic analysis of mitochondrial DNA are usually not considered in the early phase. Intraoperative abnormal observations during ptosis surgery and postoperative motility problems are signs of CPEO. If CPEO is confirmed, alternative surgical methods can correct the ptosis, like frontalis suspension.

[Cerebral ptosis. Analysis of six cases]. / Investigación clínica de la ptosis cerebral. Presentación de seis nuevos casos.

BACKGROUND: Cerebral ptosis is understood as the bilateral paralysis of eyelid elevation linked to a stroke or hemorrhage of the middle cerebral artery (MCA). It is a transient condition, independent of the evolution of the lesion. AIM: To analyze six patients with the condition. PATIENTS AND METHODS: Report of five women and one male aged 42 to 72 years. RESULTS: All suffered an infarction or hemorrhage in the territory of the middle cerebral artery of the non-dominant hemisphere and developed a bilateral palpebral ptosis. The recovery started after the fourth day. At the tenth day, eye opening was effortless and did not require frontal help, despite the persistence of hemiplegia. CONCLUSIONS: Cerebral ptosis is a mimetic dysfunction of a specific non-injured area of the cerebral cortex, originated from a nearby parenchymal damage such as the middle cerebral artery of the same hemisphere. Cerebral ptosis expresses the inhibition of the voluntary eyelid elevation center, of prefrontal location in the non-dominant hemisphere.

Scleral contact lenses for the management of complicated ptosis.

PURPOSE: To present the management of three patients suffering from ptosis of various etiologies, with scleral contact lenses. MATERIAL AND METHODS: Three patients (five eyes) with ptosis resulting from levator dehiscence due to long-term rigid gas permeable contact lens wear for keratoconus, phthisis bulbi, and myopathy due to Kearns-Sayre syndrome were identified during a 2-year period. They were fitted with scleral contact lenses in order to provide cosmesis by lifting the upper eyelid with the bulk of the lens, and simultaneously provide vision correction where applicable. RESULTS: The scleral contact lenses provided comfortable wear, significantly improved cosmesis as both palpebral aperture and marginal reflex distance were increased, and visual acuity was also subjectively and objectively improved. Two of the patients opted for the scleral contact lenses, whereas the parents of the third patient, a 10-year-old girl with Kearns-Sayre syndrome, chose to undergo ptosis surgery due to handling issues of the scleral contact lenses. CONCLUSION: Scleral contact lenses can be a useful addition to the treatment option for patients with complicated ptosis.

Isolated oculomotor nerve palsy in patients with mild head injury.

Isolated oculomotor nerve palsy following head injury is uncommon. It can only be diagnosed with confidence if it is known to have developed immediately following trauma and if adequate investigations exclude secondary causes. The recovery is only partial and this has repercussion on patients' quality of life.

Rejuvenation of the Upper Face and Periocular Region: Combining Neuromodulator, Facial Filler, Laser, Light, and Energy-Based Therapies for Optimal Results.

BACKGROUND: The upper face and periocular region is a complex and dynamic part of the face. Successful rejuvenation requires a combination of minimally invasive modalities to fill dents and hollows, resurface rhytides, improve pigmentation, and smooth the mimetic muscles of the face without masking facial expression. METHODS: Using review of the literature and clinical experience, the authors discuss our strategy for combining botulinum toxin, facial filler, ablative laser, intense pulsed light, microfocused ultrasound, and microneedle fractional radiofrequency to treat aesthetic problems of the upper face including brow ptosis, temple volume loss, A-frame deformity of the superior sulcus, and superficial and deep rhytides. RESULTS: With attention to safety recommendations, injectable, light, laser, and energy-based treatments can be safely combined in experienced hands to provide enhanced outcomes in the rejuvenation of the upper face. CONCLUSION: Providing multiple treatments in 1 session improves patient satisfaction by producing greater improvements in a shorter amount of time and with less overall downtime than would be necessary with multiple office visits.

Frontotemporal epi- and subdural approach to a cavernous sinus tumor for sphenobasal vein preservation--technical case report.

In cavernous sinus (CS) surgery, venous complication may occur in some types of venous drainage. The sphenobasal vein (SBV) drains from the superficial middle cerebral vein (SMCV) to the pterygoid venous plexus at the temporal skull base. A frontotemporal epi- and interdural approach (Dolenc approach), which is one of the CS approaches, may damage the SBV's route. We report a case of intracavernous trigeminal schwannoma that contained the SBV and discuss our modified surgical procedure that combined epi- and subdural approaches to preserve the SBV. A 64-year-old man complained of right progressive oculomotor palsy and was referred to our hospital for surgery. MR images revealed a hemorrhagic tumor in the right CS. Three-dimensional venography revealed that the SMCV drained into the pterygoid venous plexus via the SBV. After identifying the first branch of the trigeminal nerve epidurally, we incised the dura linearly along the sylvian fissure and entered the subdural space to visualize the SBV. The incision was continued to the meningeal dura of the lateral wall of the CS along the superior margin of the first branch of the trigeminal nerve, and the Parkinson's triangle was opened from the subdural side. The tumor was grossly totally removed, and the SBV was preserved. In conclusion, a frontotemporal epi- and subdural approach to the intracavernous trigeminal schwannoma can effectively preserve the SBV.

Neurological Involvement and Hepatocellular Injury Caused by a Snake With Hematotoxin Envenomation.

Venomous snakes with hematotoxin-Russell's viper (Daboia spp), Malayan pit viper (Calloselasma rhodostoma), and green pit viper (Cryptelytrops albolabris and C macrops, previously named Trimeresurus spp) are commonly found in Thailand. Coagulation factor activation, thrombocytopenia, hyperfibrinolysis, and disseminated intravascular coagulation are the main mechanisms of hemorrhaging from these snake bites. The neurological involvement and hepatocellular injury after Russell's viper bites were reported in Sri Lanka, but there is no report from Southeast Asia. This case was a 12-year-old hill tribe boy who had ptosis and exotropia of the left eye, respiratory distress, and prolonged venous clotting time, prothrombin time, and activated partial thromboplastin time; low fibrinogen and platelet count; and transaminitis after being bitten by a darkish-colored snake. He did not respond to antivenom for cobra, Malayan pit viper, or Russell's viper. However, his neurological abnormalities, respiratory failure, and hepatocellular injury improved, and coagulopathy was finally corrected after receiving antivenom for green pit viper. The unidentified snake with hematotoxin was alleged for all manifestations in this patient.

Treatment Outcomes and Predictive Factors in Pediatric Ocular Myasthenia Gravis.

OBJECTIVE: To determine demographic data, clinical presentations, investigations, treatment regimens, and clinical outcomes in pediatric ocular myasthenia gravis patients, and to find predictive factors for clinical outcomes such as resolution of disease, development of generalized symptoms, or final amblyopia. MATERIAL AND METHOD: This retrospective descriptive study of the medical records of 14 patients (male 6,female 8) less than 15 years that had ocular myasthenia gravis at Chiang Mai University Hospital between January 2006 and December 2012 was done. Univariate analysis was used to evaluate the predictive factors for clinical outcomes. RESULTS: Mean age of onset was 6.96±4.65 years (range 0.58-14 years). All patients presented with ptosis (100%) and 67% with strabismus. The mean oftotalfollow-up time is 6.30±3.84 years (range 1.25-14.25 years). None ofthe patients developed generalize myasthenia gravis. Only one patient had amblyopia at final presentation. Presenting age, gender strabismus at initial presentation, and positive neostigmine or edrophonium test did not affect resolution of disease nor final amblyopia. CONCLUSION: The most common clinical presentation in pediatric OMG was ptosis. Most patients could control the disease only by medications. There were no predictive factors affecting resolution of disease nor final amblyopia.

[Correction of paralytic lagophthalmos].

Current options for correction of paralytic lagophthalmos are either temporary (external eyelid weight placement, hyaluronic acid gel or botulinum toxin A injection) or permanent (various procedures for narrowing of the palpebral fissure, upper eyelid weights or spring implantation). Neuroplastic surgery (cross-facial nerve grafting, nerve anastomoses) and muscle transposition surgery is not effective enough. The majority of elderly and medically compromised patients should not be considered for such complicated and long procedures. Upper eyelid weight implantation thus appears the most reliable and simple treatment.

Anophthalmic syndrome: a review of management.

PURPOSE: To review and summarize current management of anophthalmic syndrome-enophthalmos, superior sulcus syndrome, lower eyelid laxity, and upper eyelid ptosis. METHODS: The authors performed a PubMed search of all articles published in English on the management of anophthalmic socket syndrome. RESULTS: A review of 37 articles demonstrated that anophthalmic syndrome occurs in a significant proportion of this patient population. Primary prevention through careful selection of primary orbital implant is ideal. Residual mild deficits can then be corrected through prosthesis modification. When modification of the prosthesis is no longer sufficient, specifically targeted procedures become necessary. CONCLUSIONS: Ocularists and oculoplastic surgeons should work together closely to treat anophthalmic syndrome. Future studies should establish uniform measurement criteria as the next step in validating the benefit and limitation of each technique.

A review of nonsurgical facial rejuvenation and the role of oxymetazoline hydrochloride ophthalmic solution, 0.1% in periorbital revitalization.

BACKGROUND: The demand for nonsurgical facial rejuvenation options is growing, yet the periorbital region remains an area of relative unmet need. This review explores nonsurgical options for facial rejuvenation and the role of oxymetazoline hydrochloride ophthalmic solution, 0.1%, in treating age-related blepharoptosis as part of periorbital rejuvenation. METHODS: Advisors experienced in facial rejuvenation met to discuss existing literature on the upper face and periorbital rejuvenation and the role of oxymetazoline hydrochloride ophthalmic solution, 0.1%, in treating facial aging. RESULTS: An array of nonsurgical options exist to address the signs of aging, including minimally invasive treatments, such as botulinum toxin injections and dermal fillers, and noninvasive therapy, such as lasers, chemical peels, and microdermabrasion. However, treating age-related ptosis in periorbital rejuvenation is mainly addressed surgically. The newly approved α-adrenergic receptor agonist oxymetazoline hydrochloride ophthalmic solution, 0.1%, provides a novel non-interventional approach to blepharoptosis. CONCLUSIONS: Facial rejuvenation is highly sought-after in this post-pandemic era. Each nonsurgical treatment option has its advantages and drawbacks. A patient-centered approach is necessary to select the appropriate procedure considering the patient's concerns and aesthetic sensibilities. The eyes are an area of primary concern for patients, yet surgery is the gold standard for treating ptosis. Oxymetazoline hydrochloride ophthalmic solution, 0.1%, is a safe and effective nonsurgical treatment for blepharoptosis.

Electroacupuncture for oculomotor nerve palsy after chemotherapy: A case report.

INTRODUCTION: Oculomotor nerve palsy (ONP) is often discovered in the ophthalmology department, manifested as ptosis with the same side, eyeball in the fixed external booth, or accompanied by limited inward, upward, and downward movements. The present case report described the effect of electroacupuncture (EA) on a breast cancer patient with ONP after chemotherapy. PATIENT CONCERNS: A 56-year-old breast cancer patient presented with severe ptosis and fixed right eye exotropia. Besides, it is challenging to perform the movement inward, upward, and downward, and with obvious diplopia. DIAGNOSES: The breast cancer patient was diagnosed with ONP, chemotherapy history. INTERVENTIONS: The patient was introduced to acupuncture department to receiving EA treatment. OUTCOMES: After 12 times of EA treatments, the symptom of ptosis was significantly improved, and the right upper eyelid can lift autonomously as same as the left eye. Besides, the patient's right lateral eye could move freely, and the symptoms of double vision disappeared. CONCLUSION: The case suggests that EA may be an effective alternative treatment for ONP.

Transient total mesencephalic locked-in syndrome after bilateral ptosis due to basilar artery thrombosis.

Locked-in syndrome (LIS) usually occurs as a result of pontine lesions and has been classified into various categories on the basis of neurologic conditions, of which transient total mesencephalic LIS is extremely rare. A 53-year-old man presented with bilateral ptosis followed by a total locked-in state. In the clinical course, the patient successfully recovered with only left slight hemiparesis and skew deviation remaining. Magnetic resonance imaging revealed multiple ischemic lesions caused by thrombosis at the top of basilar artery, including the bilateral cerebral peduncles, tegmentum of the midbrain, and the right cerebellar hemisphere. Antecedent bilateral ptosis before the locked-in state may be related to ischemia in the central caudal nucleus of the oculomotor nuclei. We should pay attention to this easily missed condition during the treatment of ischemic stroke involving the basilar artery.