Comparison between frontalis suspension and levator resection in treatment of blepharoptosis: a meta-analysis / 中华医学美学美容杂志

Objective:To compare the postoperative efficacy and complications of frontalis suspension and levator resection in the treatment of blepharoptosis.Methods:According to the Cochrane systematic review method, we searched PubMed, Medline, Cochrane Library, Wanfang database, VIP Database, and China Knowledge Network database. The randomized and non-randomized controlled trials for comparing frontalis suspension and levator resection in the treatment of blepharoptosis were included. Revman 5.3 Meta analysis software was used.Results:A total of 13 clinical trials were involved in this study, including 1308 patients. Frontalis suspension was performed in the experimental group and levator resection was performed in the control group. The OR value of postoperative efficacy between the 2 groups was 2.91, 95% CI (1.57-5.39), P<0.01, the difference was statistically significant. Postoperative lagophthalmos after frontalis suspension was better [ MD=-1.05, 95% CI (-1.43--0.68), P<0.01], the difference was statistically significant. The OR value of undercorrection between the 2 groups was 0.24, 95% CI(0.16-0.36), P<0.01, the difference was statistically significant. Conclusions:The postoperative efficacy after frontalis suspension is higher. Postoperative complications after frontalis suspension are less.

Treatment of blepharoptosis with pseudo-Graefe phenomenon caused by oculomotor nerve paralysis: report of three cases / 中华医学美学美容杂志

Objective To explore the treatment of unilateral blepharoptosis caused by oculomotor nerve paralysis with pseudo-Graefe phenomenon after craniocerebral trauma or operation.Methods Three patients suffered from blepharoptosis caused by oculomotor nerve paralysis with pseudo-Graefe phenomenon were collected in this study and the modified levator resection technique was applied to correct ptosis.The observation index after operation included the height of upper palpebral margin,the radian of double eyelid,the change of eye movement and the corresponding upper eyelid height,the eye closure function and the incidence of exposure keratitis.Results One case of oculomotor nerve palsy with moderate ptosis achieved an ideal height of upper eyelid after surgery,two cases of oculomotor nerve palsy with severe ptosis were undercorrection.All the three patients had smooth double eyelid radian,no obvious change of eye movement and corresponding upper eyelid height compared with preoperative.The two severe ptoses could close eyes well,but the moderate ptosis patient couldnot close eyes completely.Conclusions The technique of modified levator resection is an effective method to treat the moderate ptosis caused by oculomotor nerve paralysis with pseudo-Graefe phenomenon,but the results are unfavorable in the treatment of severe ptosis.

Eyelid Stretching Exercise Performed in Overcorrection after Levator Resection in Congenital Ptosis

PURPOSE: To report the clinical effect of an eyelid stretching exercise in 8 cases of overcorrected congenital ptosis after levator resection and present a literature review. CASE SUMMARY: Eyelid stretching exercise was performed by pushing the margin of the upper eyelid down. If margin reflex distance 1 (MRD1) asymmetry was larger than 1.5 mm compared with the other eyelid after the stretching exercise for 2 weeks, the exercise was extended for 1 more week. This study included 8 eyes of 8 patients who performed eyelid stretching exercise for 2 weeks when overcorrected 1 week after undergoing levator resection. We compared preoperative MRD1 and postoperative MRD1s for 1 month. Overcorrection was corrected satisfactorily in all patients with bilateral symmetry with eyelid stretching exercise for 2 weeks. Additional exercise did not affect MRD1. CONCLUSIONS: In congenital ptosis overcorrected after levator resection, medical treatment including eyelid stretching exercise could be considered before undergoing a secondary operation. Eyelid stretching exercise can be effective when performed early before fibrous tissue bonds are too firm.

Surgical Outcomes of Levator Resection in Ptosis Patients with Deep Superior Sulcus

PURPOSE: To investigate the characteristics and postoperative complications of ptosis patients with deep superior sulcus following levator resection surgery. METHODS: Records of 33 ptosis patients (59 lids) with deep superior sulcus who underwent levator resection surgery from March 2008 to May 2013 were reviewed retrospectively. Operation success rate, reoperation rate, preoperative and postoperative marginal reflex distance 1 (MRD1), and levator function were compared and postoperative complications were evaluated. RESULTS: The patient's mean age was 65.8 years. The MRD1 was -1.0 +/- 1.4 mm preoperatively, 2.5 +/- 1.2 mm at 1 month after surgery, and 2.3 +/- 1.1 mm at 3 months after surgery. Operation success rate was 84.8%. At 1 month after surgery, 52.5% of lids had lagophthalmos as a surgery complication but later all recovered. Additionally, 44.1% of the patients had worn therapeutic contact lenses postoperatively for 7.0 +/- 12.1 days. CONCLUSIONS: Occurrence rate of postoperative lagophthalmos was higher than in other previous studies suggesting a tendency for overcorrection in levator resection surgery for ptosis patients with deep superior sulcus. Additionally, levator resection surgery is cosmetically as well as functionally very effective for deep superior sulcus.

Levator Resection in the Management of Myopathic Ptosis

PURPOSE: To evaluate the results of levator resection in patients with myopathic ptosis. METHODS: The medical records of consecutive patients who underwent levator resection surgery performed for myopathic ptosis between October 2009 and March 2013 were reviewed. Indications for surgery were ptosis obscuring the visual axis and margin-reflex distance or =3 mm. We analyzed the effect of levator function and Bell's phenomenon on the rates of success and corneal complication. RESULTS: This series included six male and six female patients. Levator function was between 4 and 12 mm. We performed bilateral levator resection surgery in all patients. The mean follow-up time was 14.8 months (range, 6 to 36 months). No patient was overcorrected. Adequate lid elevation was achieved after the operation in 20 eyes. Ptosis recurred in three out of 20 eyes after adequate lid elevation was achieved. Our overall success rate was 70.8%. In three eyes with poor Bell's phenomenon, corneal irritation and punctate epitheliopathy that required artificial eye drops and ointments developed in the early postoperative period, although symptoms resolved completely within 2 months of the resection surgery. No patients required levator recession or any other revision surgery for lagophthalmos or corneal exposure after levator resection. CONCLUSIONS: Levator resection seems to be a safe and effective procedure in myopathic patients with moderate or good Bell's phenomenon and levator function greater than 5 mm.

Effect of the Simultaneous Operation of Levator Resection and Frontalis Suspension for Congenital Ptosis

PURPOSE: To determine retrospectively if a simultaneous frontalis suspension could change the result of undercorrection observed during levator resection in congenital ptosis patients with poor levator functions. METHODS: Eight eyes in the present study were from 5 infants, 4 infants had congenital ptosis and 1 infant had blepharophimosis. The average age was 3.3 years (range: 1.5 to 6.9 years). If the upper lid margin was not positioned on the superior limbus after performing levator resection under general anesthesia, the height of the upper lid margin was controlled by simultaneous frontalis suspension. RESULTS: The average follow-up period was 29.8 months. After surgery on both eyes, all 8 cases showed good results and sudden relapse did not occur. Exposed corneal erosion was observed in 6 eyes, but with artificial tears, eye drops, and ointment there were significant improvements within 1 month in all cases. At final examinations, 6 out of 8 eyes showed excellent or good results; undercorrection in 2 eyes was observed and the lateral portion of ptosis in 1 eye was observed as an eye complication. CONCLUSIONS: If undercorrection caused by levator resection occurs in patients with congenital ptosis, the combination of frontalis suspension surgery may reduce undercorrection and any recurrence that might appear after surgery.

Outcomes of Levator Resection at Tertiary Eye Care Center in Iran: A 10-Year Experience

PURPOSE: To assess outcomes of levator resection for the surgical correction of congenital and acquired upper lid ptosis in patients with fair to good levator function and evaluation of the relationship between demographic data and success of this operation. METHODS: In a retrospective study, medical records of patients with blepharoptosis who had undergone levator resection over a 10-year period and were followed for at least 3 months were reviewed. RESULTS: Overall, 136 patients including 60 (44.1%) male and 76 (55.9%) female subjects with a mean age of 20 +/- 13.8 years (range, 2 to 80 years) were evaluated, of whom 120 cases (88.2%) had congenital ptosis and the rest had acquired ptosis. The overall success rate after the first operation was 78.7%. The most common complication after the first operation was undercorrection in 26 cases (19.1%), which was more prevalent among young patients (p = 0.06). Lid fissure and margin reflex distance (MRD1) also increased after levator resection (p < 0.001). Age, sex, type of ptosis, amblyopia, levator function, MRD1, lid fissure and spherical equivalent were not predictive of surgical outcomes of levator resection. CONCLUSIONS: Levator resection has a high rate of success and few complications in the surgical treatment of congenital and acquired upper lid ptosis with fair to good levator function. Reoperation can be effective in most cases in which levator resection has been performed.

Inverse Bell's Phenomenon Following Repeated Levator Resection Surgery

PURPOSE: We report a complication involving a transient inversion of Bell's phenomenon observed following extensive levator resection performed to treat aponeurotic ptosis. CASE SUMMARY: A 22 year old female patient complained of ptosis of both eyelid. The levator function of both lid was good, and a normal corneal protection mechanism was observed. The patient underwent levator resection and several reoperation because of asymmetrical lid height and entropion. Inversion of Bell's phenomenon was observed in the postoperative period. Eye with Bell's phenomenon reverted to normal within 1 month after final operation, and there were no corneal erosion. Lubricating eyedrop was used frequently during the postoperative period. CONCLUSIONS: It is important to consider that abnormal cases of Bell's phenomenon sometimes manifest after repetitive and extensive levator resection and to keep a close watch on the cornea while providing it with ample lubrication.

Changes in Eyelid Height with Time after Levator Resection under Local Anesthesia

PURPOSE: To evaluate the factors that affect the eyelid height changes during the postoperative period in patients who underwent levator resection under local anesthesia. METHODS: Among the 242 patients that underwent levator resection under local anesthesia by the same surgeon between January on 1995 and December 2003, marginal reflex distance 1 (MRD1) measurements were performed using a caliper in 91 patients who were followed for more than 3 months. RESULTS: There were 36 males and 55 females, aged between 12 and 78 years (average of 33.6 years). The average follow-up period of the patients was 8.7 months (3 months ~ 58 months). During this period, 86 patients (94.5%) experienced satisfactory results. The average change in the MRD1 of the eyelids preoperatively, during the operation, and 1 week, 1 month, 3 months, 6 months, and 1 year postoperatively were 0.8 mm, 3.9 mm, 3.0 mm, 2.7 mm, 2.5 mm, 2.4 mm, and 2.2 mm, respectively. The MRD1 decreased 1.2 mm after 1 month and stabilized. When the levator function was greater than 8 mm, the height of the eyelids stabilized within 1 week. The worse the function of the levator palpebrae, such as in the case of congenital ptosis, the greater the correction was needed. CONCLUSIONS: Levator resection under local anesthesia is a preferable method in adjusting the height of the eyelids. In a patient with poor levator function, a greater amount of correction is needed to achieve a satisfactory eyelid height.

Frontalis Muscle Flap or Levator Resection for the Correction of Recurred Blepharoptosis

The challenge of accurately predicting eyelid height without recurrence after blepharptosis surgery is a well-known problem even in competent hands. The authors had experienced 24 recurred blepharoptosis cases from March 1999 to Feburuary 2004. 17 cases were unilateral recurred cases and the remains were bilateral cases. Previous methods in recurrent cases are as follows; Levator aponeurosis plication(2 cases), Levator resection(7 cases), Frontalis sling(15 cases). The period from first operation to secondary revision are between about 6 months to 25 years and mean period is about 6 years. The authors had managed recurrent cases with frontalis muscle advancement flap technique in 13 recurrent cases which had poor levator function or in case of frontalis muscle flap was already used. Levator resection was addressed in 11 cases which reserved levator function of more than 3mm. In Frontalis muscle flap case, the authors fixed superior-based frontalis muscle flap to tarsal plate through tunnel which was made with orbicularis oculi muscle. Among Levator resection cases, 8 cases were delayed correction cases and another 3 cases were immediate revision cases within 2 weeks after correction operation. The majority of our series recorded as satisfactory results. But, three of them gained undercorrection in follow-up period. Except for lid edema, troublesome complication just like exposure keratitis, corneal erosion was not observed. It can be safely suggested from our study that frontalis muscle advancement flap and levator resection are reasonable options in the correction of moderate to severe recurrent blepharptosis cases and the choice of recurred case management method should be accordance with levator function of patient and previously used techniques.

Outcomes of Anterior Levator Resection and Frontalis Sling in Congenital Ptosis with Poor Levator Function

PURPOSE: To compare anterior levator resection with frontalis sling in congenital ptosis with poor levator function. METHODS: We performed a retrospective review of 19 patients (25 eyes) undergoing anterior levator resection and 25 patients (28 eyes) undergoing frontalis sling for congenital ptosis with poor levator action of 5 mm or less from January 1995 to December 2001. RESULTS: The mean postoperative MRD1 were 2.4+/-0.95 mm in the anterior levator resection group and, 2.6+/-0.94 mm in the frontalis sling group. Surgical outcomes were good, fair and poor in 11, 10, and 4 eyes of the anterior levator resection group and in 14, 9, and 5 eyes of the frontalis sling group, respectively. Success rates were 84.0% and 82.1% in each group. There were no statistically significant differences between the two groups (P>0.05). CONCLUSIONS: In congenital ptosis with poor levator function, the surgical outcomes of anterior levator resection were as good as those of frontalis sling.

Outcomes of Anterior Levator Resection and Frontalis Sling in Congenital Ptosis with Poor Levator Function

PURPOSE: To compare anterior levator resection with frontalis sling in congenital ptosis with poor levator function. METHODS: We performed a retrospective review of 19 patients (25 eyes) undergoing anterior levator resection and 25 patients (28 eyes) undergoing frontalis sling for congenital ptosis with poor levator action of 5 mm or less from January 1995 to December 2001. RESULTS: The mean postoperative MRD1 were 2.4+/-0.95 mm in the anterior levator resection group and, 2.6+/-0.94 mm in the frontalis sling group. Surgical outcomes were good, fair and poor in 11, 10, and 4 eyes of the anterior levator resection group and in 14, 9, and 5 eyes of the frontalis sling group, respectively. Success rates were 84.0% and 82.1% in each group. There were no statistically significant differences between the two groups (P>0.05). CONCLUSIONS: In congenital ptosis with poor levator function, the surgical outcomes of anterior levator resection were as good as those of frontalis sling.

Comparison of Frontalis Sling and Levator Resection for Recurrence after Frontalis Sling in Congenital Ptosis

PURPOSE: To compare the success rate of two procedures frontalis sling operation and maximal levator resection for recurred congenital ptosis. METHODS: In the 44 eyes in 30 patients who had recurrence after frontalis sling using banked fascia lata, 21 eyes received frontalis sling operation using autogenous fascia lata (Group I), and the other 23 eyes received maximal levator resection with aponeurotic approach (Group II). Follow up was made at one month, three months, six months and one year after the operation. RESULTS: Six months after the operation, Group I showed 81.0% while Group II showed 78.3% in success rate. One year after the operation, Group I had 76.2%, while Group II had 73.9% in success rate. There were no significant statistical difference between the two groups (p=0.744, 0.707). CONCLUSIONS: In cases of recurrence after frontalis sling using banked fascia lata in treating congenital ptosis patients, we found the frontalis sling using autogenous fascia lata to be effective. The maximal levator resection may be used as an alternative procedure.

External Levator Resection in Mild to Moderate Unilateral Ptosis

PURPOSE: The ideal goal of the surgery for mild or moderate unilateral ptosis is to obtain symmetric palpebral fissure. The purpose of this paper is to evaluate the surgical outcome of mild or moderate unilateral ptosis patients after the procedure of external levator resection. METHODS: External levator resection with aponeurotic approach was performed on 25 mild to moderate unilateral ptosis patients with less than 2 mm MRD difference from June 1997 through May 2000. Outcome was defined as good, fair, and poor. RESULTS: Of the patients, 21 patients had congenital ptosis and 4 patients revealed acquired ptosis. Ten patients were male and 15 were female. Age ranged from 3 to 58 years(mean 19.8 years). Amount levator resection was 8~15 mm (mean 11.2 mm) with mild overcorrection. After the follow-up period 6~30 months (mean 10.8 months), 18 patients (72%) showed good results. Three patients (12%) revealed fair, and poor results were noted in 4 patients (16%). Patients with good and fair results were satisfied aesthetic aspect. CONCLUSIONS: Based on this study, mild overcorrection of levator resection was one of the ideal procedures for mild to moderate unilateral ptosis patients.

Clinical Study of Simple Levator Resection in Ptosis Patients

PURPOSE: To assess the effectiveness and results of a simplified levator resection technique for ptosis repair. METHODS: The author simplified the levator resection technique for ptosis repair using a single 6-0 prolene radial suture to control the lid height and curvature. 68 ptosis patients who received the operation were retrospectively reviewed including surgical techniques and their results. RESULTS: 46 patients (mean age 7.8 years) had congenital ptosis, and 22 patients (mean age 64.3 years) had acquired ptosis. 11 eyes of congenital ptosis and 6 eyes of acquired ptosis showed unsatisfactory surgical results. Eyelid contour deformity was present in 2 eyes of patients with acquired ptosis. CONCLUSIONS: The single stitch levator resection is simple and effective surgical procedure for ptosis repair except severe congenital ptosis which need medial and lateral crus cutting.

Surgical Results in Asymmetric Congenital Ptosis

PURPOSE: Achieving good eyelid position and symmetric palpebral fissure for asymmetric bialteral congenital ptosis would require skillful technique and a lot of experiences of surgeon. Patients were divided into two groups, A and B, in terms of preoperative MRD and the possible relationship between preoperative MRD difference. The outcome of the surgery was studied. METHODS: External levator resection with apponeurotic approach was performed for 19 patients with asymmetric bilateral congenital ptosis from October 1994 to June 2000. According to differences of MRD between the both eyes, patients were divided into two groups. Group A included 8 patients with 1.0~2.0 mm of MRD differences, and group B included 11 patients with more than 2.0 mm of MRD differences. RESULTS: Age of patients ranged from 3 to 20 years (mean 6.1 years) and follow-up period was 9 to 60 months (mean 20 months). Six patients of group A and seven patients of group B showed almost excellent symmetric palpebral fissure. Only one patient of group B had postoperative MRD difference more than 2.0 mm, and none in group A. CONCLUSIONS: Success rate was 100% in group A and 91% in group B, but no statistical difference was found between group A and group B (p>0.05).

Surgical Results of Levator Resection using the MLD (Margin Limbal Distance)in Congenital Blepharoptosis

In pediatric patients with congenital blepharoptosis, intraoperative decision of the amount of levator resection is difficult due to general anesthesia.We performed levator resection in 21 eyes of 17 patients with congenital blepharoptosis to evaluate the usefulness of the formula derived from the margin limbal distance (MLD)which was used to determine the amount of levator resection preoperatively. The amount of ptosis (interpalpebral fissure:IPF)was between 3.5 mm and 7.0 mm (mean 4.9 +/-1.2 mm), and less than 6.0 mm in 14 cases (66.4%).The levator function by Berke method was between 3.0 mm and 8.0 mm (mean 5.3 +/-1.7 mm), and between 5.0 mm and 8.0 mm in 13 cases (61.9%).The margin limbal distance was between 0 and 5.0 mm (mean 1.5 +/-1.4 mm), and less than 3.0 mm in 16 cases (76.2%).The amount of levator resection was between 10.0 mm and 22.0 mm, and between 16.0 mm and 18.0 mm in 10 cases (47.6%)which was most frequent. Of 4 patients (8 eyes)with bilateral blepharoptosis, excellent results (IPF > or= 8.0 mm)were achieved in 5 eyes (62.5%)and the other 3 eyes had fair results with IPF of over 6.0 mm.Three patients (75.0%)with bilateral blepharoptosis had symmetric IPF within 1.0 mm difference.In unilateral blepharoptosis, excellent results were achieved in 10 (76.9%)of 13 patients with IPF difference within 1.0 mm, and the other 3 patients had an IPF difference of 1.5 ~2.5 mm. The MLD formula gives the surgeon a good preoperative prediction of the amount of levator to resect, especially in pediatric patients with congenital blepharoptosis to undergo surgery under general anesthesia.

Postoperative Changes of Lagophthalmos and Lid Lag following External Levator Resection

Among the postoperative complications of ptosis surgery, lagophthalmos and lid lag have been significant and untolerable problems. In this study, progressive change of lagophthalmos and lid lag following external levator resection was examined in 109 eyes of 74 patients from November 1988 through March 1996. Lagophthalmos and lid lag were measured at postoperative 1 month, 3 to 9 months and 12 to 18 months. The relations of lagophthalmos and lid lag according to preoperative MRD, levator function, resection amount of the levator muscle were analyzed. Lagophthalmos measured average 1.11mm and lid lag revealed average 4. 73mm at postoperative 11 to 84 months (mean 22.2 months). At the postoperative 1 year, lagophthalmos and lid lag were significantly decreased and decreasing amount measured 1.17mm and 0.90mm, respectively. Seventy eyes showed lagophthalmos less than 1mm at mean 13 months postoperatively. The postoperative change of lagophthalmos and lid lag had relation to the preoperative levator function.

The Effect of External Levator Resection in Blepharoptosis with Poor Levator Function

The postoperative complications of frontalis sling for severe blepharoptosis with poor levator function have included undercorrection, overcorrection, exposure keratitis due to lagophthalmos, lid lag. upper lid asymmetry etc, External levator resection with aponeurotic approach was performed for 77 blepharoptosis patients (106 eyelids) with poor levator function from October 1987 through April 1996 at the Department of Ophthalmology, Yeungnam University, College of Medicine. Unilateral blepharoptosis were 44 eyelids and bilateral cases included 62 eyelids. Levator function was measured 4nim in 23 eyelids, Slum in 22 eyelids and 0-2iBin in 61 eyelids, After the follow up periods of 12-108 months (mean 36.3 months) , satisfactory resuite have been achieved in 44 eyelids (100%) of unilateral ptosis and in 30 eyelids (90.9%) of bilateral ptosis. All eyelids with 4mm levator function was successful, 22 eyelids (86.4%) with 3mm levator function were satisfactory and 61 eyelids (95. 1%) with 0-2mm levator function revealed satisfactory result. Postoperative complications included entropion (4 cases) , undercorection (2 cases) , corneal opacity (I case) and corneal ulcer (1 case). Based on this study, external levator resection could were one of the ideal techniques for severe ptosis with poor to absent. levator function.

The Operation of Unaffected Normal Eye in Unilateral Ptosis

Moderate to severe unilateral ptosis has previously been treated with levator resection or frontalis sling and cosmetic double fold in the opposite eyelid. This method often resulted in undesirable asymmetrical lid lag phenomenon in down gaze. From December 1991 to December 1994, we treated 65 cases of unilateral ptosis with frontalis sling or levator resection, and simultaneously cosmetic frontalis sling have been performed in the unaffected normal eyes of 41 patients and cosmetic double fold have been performed in the unaffected normal eyes of 11 patients. After 6 months of operation, authors survey the patients content. The number of cases of content were 4(36.36%) in 11 cosmetic double fold group and 31(75.6%) in 41 cosmetic frontalis sling group. The content after cosmetic frontalis sling was higher than cosmetic double fold. Asymmetrical lid lag phenomenon on downward gaze which is inevitable complication postoperatively was reduced by means of cosmetic frontalis sling of unafeected normal eye in unilatral ptosis. The authors expect that the patient will be more satisfied with the result of symmetrical lid lag in down gaze after cosmetic frontalis sling of unaffected normal eye in aesthetic aspect.