Temporalis Muscle Transfer for the Treatment of Lagophthalmos in Patients With Leprosy: Refinement in Surgical Techniques to Prevent Postoperative Ptosis.

Facial paralysis resulting from leprosy has a serious impact on the entire face especially in the areas innervated by the facial nerves. In particular, lagophthalmos in patients with leprosy causes exposure keratitis, corneal, and conjunctival dryness, which can progress to blindness and disfigurement. Recently, we conducted 4 different temporalis muscle transfer (TMT) methods over the last 4 years to reduce ptosis. The methods used included Brown-McDowell, McCord-Codner, modified Gillies-Anderson, and modified Gillies. Seventy-five TMT operations in 60 patients were performed between 2011 and 2014. The mean age was 70.1. Fifteen patients had bilateral TMT procedures. As a result, ptosis appeared in 14(18.7%) of 75 TMT procedures for 4 years. To prevent or correct this complication, the following 4 technical refinements have simplified the surgery and yield better surgical outcomes. First, an increase in the length of the temporalis muscle flap to approximately 8 cm with a parallel course to the lateral canthus will reduce oblique pull. Second, the width of the fascia sling in the upper eyelid is narrowed (3-4 mm) to reduce weight on the eyelid. Third, the fascia sling in the upper lid should not be located along the full length of the upper lid but terminate 3.5 cm medial to lateral canthal tendon and in other words, should not be tied at the medial canthal tendon to reduce tension and weight. Lastly, the fascia sling in the eyelid should be located shallow (probably in subdermal layer) and as near as possible to the lid margin to prevent any functional disturbance in levator aponeurosis.

Gold weight implants in the management of lagophthalmos in leprosy patients.

OBJECTIVES: To evaluate the use of gold weights as upper lid implants in the management of lagophthalmos due to facial nerve affection in leprosy patients. DESIGN: Gold implants of various weights were inserted in the upper eyelids of 12 patients with leprosy. Pre- and post-operative lid closures were recorded and patients were followed up for 1 year. RESULTS: Despite early satisfactory results with good closure, six out of 12 implants were extruded within the first year. Two more implants had to be removed due to chronic inflammatory reaction. CONCLUSION: Long term result of gold weight implants in leprosy patient is unsatisfactory and needs further evaluation.

Lid surgery in patients affected with leprosy in North-Eastern Nigeria: are their needs being met?

Corneal blindness is second only to cataract as a cause of blindness in leprosy patients. Eyelid surgery provided by trained paramedical staff can often prevent blindness in these patients. We sought to determine the extent to which paramedic personnel are meeting the eyelid surgical needs of these patients and to investigate the barriers that may be preventing them from seeking surgery. A total of eight leprosy settlements in north-eastern Nigeria were selected for this study. In these villages, 480 residents who were 30 years of age or older who had been diagnosed as having leprosy had their eyes examined for the presence of lagophthalmos, entropion/trichiasis and evidence of surgery for either of these conditions. Patients who had not been operated on for either of these conditions were questioned to determine their reasons for not seeking surgery. One hundred and sixteen (12.1 %) eyes were in need of surgery while 5.1 % of eyes had been operated upon. The surgical coverage for eyelid surgery was 30%; lagophthalmos had a better surgical coverage of 44.4% compared to entropion/trichiasis, which had 24.7% coverage. Lack of awareness about the treatment available was the most common reason given for not seeking surgery. This study shows that despite the presence of trained paramedical staff in the community, the eyelid surgical needs of these patients are not being met primarily because the level of awareness about the availability of effective treatment still remains low. In addition, the readiness of eye-care staff to visit these settlements was disappointing. Extra efforts will have to be made.

[Bilateral lagophthalmos in lepromatous leprosy. Case report]. / Lagoftalmos bilateral en paciente con lepra lepromatosa. Caso clínico.

CASE REPORT: A case of bilateral facial palsy with paralytic ectropion, lagophthalmos and corneal damage secondary to corneal exposure in a long-standing patient with lepromatous leprosy is presented. Correction of paralytic ectropion was performed by medial cantoplasty, tarsal strip and Medpor lower eyelid spacer implantation. Lagophthalmos was corrected by gold weight implant in the upper tarsus. DISCUSSION: Ocular findings in leprosy appear in 72% of patients. Facial nerve palsy occurs in 3-19.8%, being bilateral in 5%. In long standing cases with corneal complications secondary to exposure, surgical treatment is required.

Lagoftalmos bilateral en paciente con lepra lepromatosa. Caso clínico / Bilateral lagophthalmos inlepromatous leprosy. Case report

CASE REPORT: A case of bilateral facial palsy with paralytic ectropion, lagophthalmos and corneal damage secondary to corneal exposure in a long-standing patient with lepromatous leprosy is presented. Correction of paralytic ectropion was performed by medial cantoplasty, tarsal strip and Medpor lower eyelid spacer implantation. Lagophthalmos was corrected by gold weight implant in the upper tarsus. DISCUSSION: Ocular findings in leprosy appear in 72 per cent of patients. Facial nerve palsy occurs in 3-19.8 per cent, being bilateral in 5 per cent. In long standing cases with corneal complications secondary to exposure, surgical treatment is required.

Lagophthalmos surgery in leprosy: findings from a population-based survey in Korea.

Lagophthalmos continues to be a serious problem in cured leprosy patients. We conducted a population-based survey of lagophthalmos surgical coverage (LSC), barriers to lagophthalmos surgery and outcome of lagophthalmos surgery in leprosy patients in South Korea. In our survey, there were 60 patients with lagophthalmos who had needed surgery (> 5 mm gap), 34 of whom had received surgery, resulting in a lagophthalmos surgery coverage of 57%. Among the 34 patients who had received lagophthalmos surgery, 18 needed further surgery. Among those who had never had surgery, none of the demographic indicators predicted surgical uptake; the primary reason given for failure to have surgery was lack of knowledge about it. Outcome of surgery (by eye) showed that 29% of eyes still had a gap of 5 mm or more. The frequency of symptoms (tearing, blurring of vision, pain, etc.) was high. Even in settings with a good eye care infrastructure, such as Korea, uptake of surgery can still be low and results may not be satisfactory to patients. There is a need for practical guidelines for leprosy control programmes in the areas of (a) patient recognition, (b) patient education, (c) monitoring the uptake of surgery, and (d) monitoring the outcome of surgery to ensure the best possible outcome.

Lid surgery to reduce discomfort produces an unexpected improvement in visual acuity--a case presentation.

A significant cause of blindness in leprosy is corneal scarring secondary to corneal anaesthesia and lagophthalmos (Brand & ffytche 1985). Such patients may continue to experience considerable ocular discomfort, particularly when there is associated ectropion of the lower lid, with inflammation of the exposed tarsal conjunctiva (Courtright & Johnson 1991). Where visual outcome is no longer the primary consideration, one may hesitate to subject patients to surgery, particularly in relatively unsophisticated field conditions, attempting instead to relieve the patient's discomfort by conservative treatment such as frequent topical ocular lubricants, use of protective spectacles or eye shades etc. A case is presented here in which minor surgery aimed solely at relieving ocular discomfort resulted in an unexpected improvement in visual acuity. This suggests that there are instances where a more aggressive approach to treatment of even severely damaged eyes could prove more rewarding than anticipated.

Tratamento cirúrgico da triquíse maior / Surgical treatment for larger trichiasis

O objetivo deste trabalho foi conhecer as características dos portadores de triquíse maior e a resposta ao tratamento (cirurgia de Van Millingen). Foram avaliados 100 pacientes portadores da patologia e observou-se que a doença foi mais frequente em pacientes acima da sexta década de vida, portadores de tracoma cicatricial, cirurgia palpebral prévia, blefarite e meibomite. A pálpebra superior e a inferior foram acometidas nas mesmas proporçöes. A resposta ao tratamento cirúrgico foi pior nos portadores de triquíase associada ao entrópio, havendo necessidade de nova cirurgia em 23,1 p/c dos pacientes. Os autores responsabilizam o caráter crônico-evolutivo das patologias de base pelas falhas do tratamento

Temporalis muscle transfer in the correction of lagophthalmos due to leprosy.

In the correction of lagophthalmos due to leprosy neuritis temporalis muscle transfer (TMT) is used to provide a motor to assist in lid closure. This study of TMT in 51 eyes was carried out to assess the effectiveness of TMT in achieving lid closure and corneal protection. The average lid gap preoperatively on light closure was 7.3 mm which was reduced to 3.2 mm on final follow-up. The average lid gap pre-operatively on tight closure was 5.3 mm which was reduced to 0.4 mm at final follow-up. It is possible to train patients with partial or total anesthesia of the cornea in a visual THINK-BLINK reflex. The common complications encountered were ectropion in 6 eyes (12%) and ptosis in 3 eyes (6%).

[External canthopexy using the Edgerton-Montandon procedure in lagophthalmos of leprosy patients. Technique and indications. Apropos of 30 cases]. / La canthopexie externe selon le procédé d'Edgerton-Montandon dans les lagophtalmies des malades de la lèpre. Technique et indications. A propos de trente cas.

This paper deals with the results observed in 21 ancient leprosy patients suffering from lagophthalmos (13 of whom suffered from bilateral lagophthalmos) and treated by the Edgerton-Montandon surgical procedure which associates lateral canthopexy and tarsorraphy. Eighteen of the 21 treated patients were reviewed at one month after the procedure and, overall, results could be evaluated for 30 eyes. Improvement was noted in all of the 30 eyes and, globally, the residual palpebral fissure (during voluntary closing of the eyes by the patient) decreased from 6.7 mm before the procedure to 1.8 after the procedure. The following recommendations may be proposed. For young patients with intact corneal sensation, the Gillies procedure remains the procedure of choice to correct lagophthalmos. For older patients with corneal anesthesia, at high risk of blindness, the Edgerton-Montandon procedure should be recommended.

Results of surgical procedures for the correction of foot-drop and of lagophthalmus due to leprosy.

Leprosy mutilations of the muscles and skeleton can be relieved by reconstructive surgery, but evaluation of the results of these operations is seldom undertaken. Between 1975 and 1984, 59 leprosy patients were operated on at the Marie Adelaide Leprosy Centre, Karachi, Pakistan, for lagophthalmus with the transposition of the posterior tibial muscle. We were able to re-examine 39 patients: tibialis posterior transposition was performed 25 times, and temporalis transposition was carried out 33 times; 18 of the 25 patients with the tibialis posterior transposition were pleased with the result, 7 were not: 21 patients could extend their feet above the neutral position; 24 of the patients with the temporalis transposition were satisfied, 9 were not: complete closure was demonstrated in 21 eyes; Persistent corneal damage was noted in 15 eyes; 12 of the 23 male patients cared for themselves, 16 lived with their families; 7 of the 8 female patients lived with their families. The results of the rehabilitation, in relation to the degree of mutilation, are considered satisfactory for a developing country. These surgical procedures give a good result, provided they are followed by intensive physiotherapy.