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.

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.

Double Eyelid Tape as a Treatment Option for Severe Ptosis in Patients With Myotonic Dystrophy Type 1.

ABSTRACT: Myotonic dystrophy is a systemic disorder associated with progressive muscle weakness of the limbs and multiorgan dysfunction. This condition commonly affects the levator palpebrae superioris muscle, which leads to ptosis and eventually affects patients' activities of daily living. The effects of ptosis on activities of daily living are usually overlooked; therefore, the importance of treatment is underestimated, and surgical procedures are considered infeasible in patients with preexistent levator palpebrae superioris muscle weakness. This case report describes the case of a middle-aged man with myotonic dystrophy type 1, who presented with ptosis, which significantly restricted his participation in rehabilitation and activities of daily living secondary to a limited visual field. He was evaluated by an ophthalmologist; however, surgery was contraindicated in view of the high risk of complications, such as exposure keratitis and corneal ulcer. Double eyelid tapes were used as a nonsurgical intervention, which significantly increased the palpebral fissure height and improved the visual field, with a higher modified functional index score. Double eyelid tapes may serve as an effective, safe, and reliable therapeutic option for severe ptosis in patients with myotonic dystrophy.

[Management of ptosis]. / Conduite à tenir devant un ptosis.

Ptosis is defined as a drooping of the upper eyelid. It often results in functional and/or aesthetic impairment. Although often benign, ptosis may be the first symptom of a life-threatening condition (carotid dissection, intracranial aneurism, generalized myasthenia). Only a rigorous, systematic and clinical examination will allow the physician to distinguish "benign ptosis" from "urgent ptosis". The history should attempt to detect a daily variation in the ptosis, suggesting myasthenia gravis. Pupillary examination should rule out myosis, which would suggest Claude Bernard-Horner's syndrome (secondary to an internal carotid dissection until proven otherwise), or mydriasis, suggesting an intracranial aneurism. Once an emergency has been ruled out, the clinical examination should assess the levator muscle strength (helpful for determining the underlying etiology) and the Bell's phenomenon (the lack of which is predictive of postoperative corneal exposure). The amount of ptosis is not related to its etiology. At the conclusion of the examination, the physician must be able to classify the ptosis as either pseudoptosis, aponeurotic ptosis, neurogenic ptosis, myogenic ptosis, or junctional ptosis (myasthenia). Except for "urgent ptosis", requiring multidisciplinary medical treatment, surgery is the mainstay of treatment. The surgical technique is based on the etiology of the ptosis, the strength of the levator muscle and the phenylephrine test.

[Treatment of congenital ptosis in a low-income country: polypropylene frontalis sling at the African Institute of Tropical Ophthalmology]. / Traitement du ptosis congénital dans un pays à faible revenu : suspension du releveur au muscle frontal par le polypropylène à l'Institut d'Ophtalmologie tropicale de l'Afrique (IOTA).

INTRODUCTION: Treatment of congenital ptosis is exclusively surgical; the frontalis sling method is most appropriate when the ptosis is severe, with no upper eyelid levator function. This surgery typically utilizes various materials (autologous fascia lata, silicone, nylon, or polypropylene bands, etc.). MATERIALS AND METHODS: This was a retrospective descriptive study of 22 children under 16 years of age, treated for congenital ptosis by frontalis suspension of the levator muscle of the upper eyelid using the polypropylene technique, between January 1, 2014 and June 30, 2017 at the African Institute of Tropical Ophthalmology teaching hospital. RESULTS: In our study, the surgical result (prior to correction of recurrences) was satisfactory in 81.82 % of cases, with a recurrence rate of 13.64 %. The mean follow-up was 14 months, ranging from 4 to 25 months. DISCUSSION: The use of polypropylene provides encouraging results in ptosis surgery, while also offering the advantage of being low cost and more available. Its use in developing countries deserves special attention.

Comportamiento clínico quirúrgico de la exotropía de gran ángulo / Clinical and surgical behavior of large-angle exotropia

RESUMEN Objetivos: Describir algunas características clínicas de la exotropía de gran ángulo y determinar su resultado quirúrgico. Métodos: Se realizó un estudio descriptivo retrospectivo de 35 pacientes atendidos en el Hospital Oftalmológico "Amistad Cuba-Argelia", en la Wilaya de Ouargla, Argelia, en el período enero 2014 - diciembre 2017. Se analizó el comportamiento de algunas variables relacionadas con la exotropía, como fueron la edad del paciente, el sexo, el color de la piel, las alteraciones oftalmológicas asociadas, el grado de ambliopía, el defecto refractivo asociado, el ángulo de desviación preoperatorio y posoperatorio y el tipo de cirugía realizada. Resultados: Predominó el grupo etario entre 24 y 29 años de edad con el 25,7 por ciento; el 51,4 por ciento representó al sexo femenino; el color de la piel negra fue el más frecuente con 48,6 por ciento; la ptosis palpebral correspondió al 11,4 por ciento de las alteraciones oftalmológicas asociadas y al 68,6 por ciento sin alteraciones; la ambliopía moderada se registró en el 42,9 por ciento de los casos; el defecto refractivo más observado fue el astigmatismo miópico con el 37,1 por ciento; el ángulo de desviación preoperatorio más significativo se encontró en el grupo de 71-80 dioptrías con 37,2 por ciento. A los tres meses de la cirugía el 91,4 por ciento de los pacientes se encontró en ortoforia (± 8 dioptrías) y al año de la cirugía el 94,3 por ciento se mantenía en ortoforia. El retroceso de ambos músculos rectos laterales (10,0 mm) más la resección de un músculo recto medio (7 mm) se realizó en el 37,2 por ciento de los pacientes. Conclusiones: La casi totalidad de los pacientes con exotropía de gran ángulo logran el alineamiento ocular y consiguen una mejoría en la calidad visual(AU)

ABSTRACT Objectives: Describe some clinical characteristics of large-angle exotropia and determine its surgical outcome. Methods: A retrospective descriptive study was conducted of 35 patients attending Cuba-Algeria Friendship Ophthalmological Hospital in the wilayah of Ouargla, Algeria, from January 2014 to December 2017. Analysis was carried out of variables related to exotropia, such as the patients' age, sex, skin color, associated ophthalmological alterations, degree of amblyopia, associated refractive defect, pre- and post-operative angle of deviation, and type of surgery performed. Results: The 24-29 year age group prevailed with 25.7 percent; 51.4 percent of the patients were female; black skin color was the most common with 48.6 percent; eyelid ptosis represented 11.4 percent of the associated ophthalmological alterations and 68.6 percent without alteration; moderate amblyopia was present in 42.9 percent of the cases; the most frequent refractive defect was myopic astigmatism with 37.1 percent; the most significant preoperative angle of deviation was found in the 71-80 diopter group with 37.2 percent. Three months after surgery, 91.4 percent of the patients were orthophoria (± 8 diopters) and at one year 94.3 percent remained orthophoria. Bilateral lateral rectus muscle recession (10.0 mm) plus resection of a medial rectus muscle (7 mm) was achieved in 37.2 percent of the patients. Conclusions: Practically all patients achieved ocular alignment and improved their visual quality(AU)

Deficiencia monocular de la elevación con esotropía / Monocular elevation deficiency with esotropia

RESUMEN La deficiencia monocular de la elevación se define como la limitación de la elevación del ojo afectado desde cualquier posición de la mirada, con ducciones normales en todas las demás posiciones. La pseudoptosis se puede presentar en posición primaria de la mirada; sin embargo, el 25 por ciento de los casos puede mostrar una ptosis verdadera. Se presenta un paciente masculino de 11 años de edad con antecedentes de estrabismo hacia adentro desde que nació, quien llevó tratamiento con oclusiones y cristales desde el primer año de edad. Al examen oftalmológico presentaba una agudeza visual mejor corregida de 1,0/0,4; a 6 metros en el ojo derecho 30 ∆ b externa ~18 ∆ b superior y en el ojo izquierdo 30 ∆ b externa ~18 ∆ b inferior; a 33 centímetros en el ojo derecho 30 ∆ b externa ~25 ∆ b superior y en el ojo izquierdo 30 ∆ b externa ~25 ∆ b inferior y limitación de la elevación en todas las posiciones horizontales de la mirada en el ojo derecho. Se realizó la prueba de ducción forzada y se encontró una restricción del recto inferior derecho, por lo que se decidió retroinsertar este músculo y ambos rectos medios. Se indicó la corrección óptica y la rehabilitación con oclusiones que mejoró la visión a 1,0/0,7. La cirugía correctiva logró la ortotropía y la mejoría de la agudeza visual(AU)

ABSTRACT Monocular elevation deficiency is defined as a limitation in the elevation of the affected eye from any position of gaze with normal ductions in all other positions. Pseudoptosis may occur in the primary position of gaze, but 25 percent of the cases are true ptosis. A case is presented of a male 11-year-old patient with a history of inward strabismus since birth, treated with occlusions and lenses as of his first year of life. At ophthalmological examination, best corrected visual acuity was 1.0/0.4; at 6 meters in the right eye 30 ∆ b outer ~18 ∆ b upper, and in the left eye 30 ∆ b outer ~18 ∆ b lower; at 33 centimeters in the right eye 30 ∆ b outer ~25 ∆ b upper, and in the left eye 30 ∆ b outer ~25 ∆ b lower, and elevation limitation in all horizontal gaze positions of the right eye. The forced duction test revealed a restriction in the lower right rectus muscle. It was thus decided to insert back the right rectus muscle and both medial rectus muscles. Optical correction and rehabilitation with occlusions improved the patient's vision to 1.0/0.7. Corrective surgery achieved orthotropy and improved visual acuity(AU)

Ptosis and macroglossia in a woman with systemic light-chain amyloidosis.

BACKGROUND: Amyloidosis is a rare and variable disease, characterized by extracellular deposits of amyloid protein in different tissues and organs. Patients may present with a range of symptoms, depending on the extent of involvement. Rapid, accurate diagnosis is still challenging in clinical practice. CASE REPORT: A 72-y-old woman presented with a 1-y history of droopy upper left eyelid, resulting in decreased visual acuity, and progressive tongue swelling, resulting in dysarthria, dysphagia, and sleep apnea. Physical examination revealed puffy eyes, moderate swelling up to 1 cm of the upper left eyelid, swollen submental region, and protrusion of the tongue, causing an inability to close the mouth. An abnormal serum free light chain ratio implied the presence of monoclonal gammopathies, and Congo red staining revealed amyloid deposits in specimens from both the tongue and left eyelid. Therefore, a diagnosis of systemic light-chain (AL) amyloidosis was confirmed. The patient then received oral melphalan therapy and surgical intervention for macroglossia. Clinical symptoms including dysarthria, dysphagia, and sleep apnea were under control at 6-month follow-up. CONCLUSIONS: We report an uncommon case presenting initially with both ptosis and macroglossia, for which a final diagnosis of systemic AL amyloidosis was made. Detailed history and laboratory investigation must be implemented on suspicion of amyloidosis, because early recognition of amyloid-associated diseases and appropriate treatment can improve clinical outcomes.

Ophthalmologic Clinical Features of Facial Nerve Palsy Patients.

PURPOSE: To understand the ophthalmic clinical features and outcomes of facial nerve palsy patients who were referred to an ophthalmic clinic for various conditions like Bell's palsy, trauma, and brain tumor. METHODS: A retrospective study was conducted of 34 eyes from 31 facial nerve palsy patients who visited a clinic between August 2007 and July 2017. The clinical signs, management, and prognosis were analyzed. RESULTS: The average disease period was 51.1 ± 20.6 months, and the average follow-up duration was 24.0 ± 37.5 months. The causes of facial palsy were as follows: Bell's palsy, 13 cases; trauma, six cases; brain tumor, five cases; and cerebrovascular disease, four cases. The clinical signs were as follows: lagophthalmos, 24 eyes; corneal epithelial defect, 20 eyes; conjunctival injection, 19 eyes; ptosis, 15 eyes; and tearing, 12 eyes. Paralytic strabismus was found in seven eyes of patients with another cranial nerve palsy (including the third, fifth, or sixth cranial nerve). Conservative treatments (like ophthalmic ointment or eyelid taping) were conducted along with invasive procedures (like levator resection, tarsorrhaphy, or botulinum neurotoxin type A injection) in 17 eyes (50.0%). Over 60% of the patients with symptomatic improvement were treated using invasive treatment. At the time of last following, signs had improved in 70.8% of patients with lagophthalmos, 90% with corneal epithelium defect, 58.3% with tearing, and 72.7% with ptosis. The rate of improvement for all signs was high in patients suffering from facial nerve palsy without combined cranial nerve palsy. CONCLUSIONS: The ophthalmic clinical features of facial nerve palsy were mainly corneal lesion and eyelid malposition, and their clinical course improved after invasive procedures. When palsy of the third, fifth, or sixty cranial nerve was involved, the prognosis and ophthalmic signs were worse than in cases of simple facial palsy. Understanding these differences will help the ophthalmologist take care of patients with facial nerve palsy.

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.

Investigación clínica de la ptosis cerebral: presentación de seis nuevos casos / Cerebral ptosis: analysis of six cases

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.

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.

Lymphatic malformation with acquired Horner syndrome in an infant.

An infant presented with right upper eyelid ptosis and was subsequently diagnosed with acquired Horner syndrome. Further evaluation revealed a right-sided cervicothoracic lymphatic malformation. At 13 weeks of age, the child underwent percutaneous intracystic sclerotherapy with a mixture of sodium tetradecyl sulphate and ethanol. Twenty-one weeks after initial treatment, ophthalmic examination showed complete resolution of the blepharoptosis and pupillary miosis. Percutaneous sclerotherapy not only effectively treated the space-occupying lymphatic malformation but also reversed the Horner syndrome that was presumably induced by neural tension (more likely) or compression.

[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.

[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.

Open source modular ptosis crutch for the treatment of myasthenia gravis.

INTRODUCTION: Pharmacologic treatment of Myasthenia Gravis presents challenges due to poor tolerability in some patients. Conventional ptosis crutches have limitations such as interference with blinking which causes ocular surface drying, and frequent irritation of the eyes. To address this problem, a modular and adjustable ptosis crutch for elevating the upper eyelid in Myasthenia Gravis patients has been proposed as a non-surgical and low-cost solution. AREAS COVERED: This paper reviews the literature on the challenges in the treatment of Myasthenia Gravis globally and focuses on a modular and adjustable ptosis crutch that has been developed by the Medical Device Laboratory at the University of Cape Town. EXPERT COMMENTARY: The new medical device has potential as a simple, effective and unobtrusive solution to elevate the drooping upper eyelid(s) above the visual axis without the need for medication and surgery. Access to the technology is provided through an open source platform which makes it available globally. Open access provides opportunities for further open innovation to address the current limitations of the device, ultimately for the benefit not only of people suffering from Myasthenia Gravis but also of those with ptosis from other aetiologies.

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.

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.