Myopathic Blepharoptoses: A New Classification System.

PURPOSE: Myopathic blepharoptoses (ptoses) is a complex group of disorders. To date, no formal categorization scheme has been developed based on associated ocular and systemic findings, genetic fingerprint, treatment, and prognosis for each ptosis in this group. We report a new classification scheme for myopathic ptoses. METHODS: Literature review and classification development. RESULTS: A new classification scheme of myopathic ptoses includes isolated static myopathic ptosis (congenital ptosis), static myopathic ptosis associated with aberrant innervation and those associated with periocular abnormalities, and progressive myopathic ptoses that affect the levator muscle and other muscle groups in childhood and adulthood. CONCLUSIONS: Making the distinction of myopathic ptosis type early will maximize patient outcomes by optimizing surgical and systemic management and facilitating the recruitment of subspecialists to care for patients with these challenging conditions.The authors present a comprehensive and effective myopathic ptosis classification scheme to optimize surgical management and facilitate subspecialty care.

Comparing the outcomes of severe versus mild/moderate ptosis using closed posterior levator advancement.

Traditionally, posterior eyelid surgical approaches such as Müller's muscle-conjunctival resection (MMCR) have been utilised with great success for mild cases of ptosis, with external levator approaches having been used for more severe cases of ptosis. We present a new technique which we label closed posterior levator advancement (CPLA) for the correction of all grades of ptosis. This article is a retrospective cohort study reviewing patients with mild, moderate, and severe ptosis over a 6-year period, treated by a single surgeon using CPLA. Minimum follow-up was 3 months. Patients with good levator function (levator palpebrae superioris (LPS) function >10 mm) without concomitant procedures were subdivided based on margin-to-reflex-distance-1 (MRD1) into mild-to-moderate ptosis (MRD1 > 1.5 mm) and severe ptosis (MRD1 ≤ 1.5 mm) cohorts. The outcome measures were preoperative and postoperative MRD1, lid contour, intereye symmetry, complications, and revision rates. 393 eyes of 313 patients were identified. 91 eyes in the mild-to-moderate cohort had a preoperative MRD1 of 2.38 mm, and 302 eyes in the severe cohort had a preoperative MRD1 of 0.27 mm. Postoperatively, MRD1 was 3.86 mm and 3.49 mm, respectively. There were no significant complications in both cohorts, and revision rates were 3.3% (3 of 91 eyes) in the mild-to-moderate and 2% (6 of 302 eyes) in the severe cohorts. Upper-eyelid contour was satisfactory in 98.2% of eyes, and 97.5% intereye symmetry within 1 mm was observed. Our results show an effective correction of all ptosis grades with satisfactory cosmetic outcomes and low complication and revision rates.

Improvement of the Marginal Reflex Distance-1 in Blepharoptosis Surgeries.

The aim of this study was to predict the improvement of the marginal reflex distance (MRD1) in each blepharoptosis surgery.In PubMed and Scopus, the search terms 1. (blepharoptosis) AND 2. (surgery) AND 3. (levator OR outcome OR MRD OR function OR ptosis amount) were used and 1268 titles were found. Among them 28 papers were analyzed: Aponeurotic surgery (A-group, 8), Muller muscle resection (M-group, 10), Levator resection (L-group, 4), and Frontalis suspension (F-group, 6).The preop-MRD1 was greatest in L-group (1.7 ± 1.0 mm) followed by the A-group (1.3 ± 0.5 mm) and the M-group (1.3 ± 0.5 mm). The F-group had the lowest (-0.4 ± 0.7 mm). Age was oldest in the M-group (58.6 ± 11.9 years) followed by the A-group (42.4 ± 18.9 years) and the F-group (27.2 ± 17.9 years). The L-group was the youngest (18.9 ± 11.5 years). The mean improved amount of MRD1 (ΔL) was 2.15 ± 0.90 mm. The ΔL was different among the four operative methods. The F-group was greatest (2.4 ± 1.5 mm) followed by the A-group (2.3 ± 0.5 mm) and the M-group (2.0 ± 0.6 mm). The L-group had the least improved amount of MRD1 (1.8 ± 0.8 mm). There were significant differences between the groups (P < 0.05), except between the F-group and the A-group (P = 0.284). The mean follow-up period was 8.1 ± 7.0 months. In the 3 groups except A-group, the ΔL decreased in follow-up periods, with different degree of decrement. Only in A-group, ΔL increased slightly in follow-up periods. We think this is due to relatively well preserved levator function and short follow-up period (5.4 ± 3.3 months) of A-group patients.The results of this review can be used in choosing blepharoptosis correction methods.

Classificação clínica de ptose da cauda do supercílio / Clinical classification of brow ptosis

INTRODUÇÃO: O estudo do supercílio se emoldura como um grande desafio para a cirurgia plástica por sua complexa relação com as estruturas faciais. O objetivo é descrever uma classificação clínica de ptose da cauda do supercílio. MÉTODOS: Estudo transversal, com pacientes de ambos os sexos, com idade de 18 a 100 anos, subdivididos em três grupos segundo a faixa etária. Grupo 1: 18 a 30 anos, Grupo 2: 31 a 60 anos e Grupo 3: 61 a 100 anos. Realizaram-se três medidas de cada lado por examinadores distintos, sem que cada um soubesse o valor da aferição dos demais. RESULTADOS: Total de 90 pacientes, com idades variando entre 18 e 94 anos, sendo 39 (43,3%) do sexo masculino e 51 (56,7%)do sexo feminino. As medidas do Grupo 1, considerado como normal, com média de idade de 26,7 anos, e com média de 2,14 cm em relação a medidas da ptose da cauda do supercílio. Já no Grupo 2, média da faixa etária foi de 44,2 anos e a média foi de 1,9 cm. No Grupo 3, média de idade de 72,6 anos com média de 1,27 cm. A tabela com a Classificação da Ptose da Cauda do Supercílio, em que se atribuiu a cada intervalo um grau de ptose, variando de grau I ao grau IV. Cada grau foi correlacionado com um intervalo numérico em que: > 1,8 cm representa a normalidade; 1,7-1,5 cm o grau I de ptose; 1,4-1,2 cm o grau II de ptose;1,1-0,9 cm o grau III de ptose e < 0,8 cm o grau IV de ptose. Em referência à indicação cirúrgica, essa teve sua indicação nos graus II, III e IV. CONCLUSÃO: A medida objetiva da posição da cauda do supercílio possibilitou classificação do grau de ptose e orientação quanto à necessidade de intervenção cirúrgica.

INTRODUCTION: The study of the eyebrow is a great challenge for plastic surgery because of its complex relationship with facial structures. The present study aims to describe a clinical classification of brow ptosis. METHODS: A cross-sectional study with patients of both sexes and ages ranging from 18 to 100 years, subdivided into 3 groups according to age. Group 1: 18 to 30 years of age, Group 2: 31 to 60 years of age, and Group 3: 61 to 100 years of age. Three measurements were taken on each side by different examiners blinded to each other's results. RESULTS: A total of 90 patients, with ages ranging from 18 to 94, including 39 (43.3%) men and 51 (56.7%) women, were studied. Group 1, with a mean age of 26.7 years was considered normal, with mean brow ptosis of 2.14 cm. In Group 2, with a mean age of 44.2 years, the mean brow measurement was 1.9 cm. In Group 3, the mean age was 72.6 years and the mean brow measurement was 1.27 cm. The table outlining the brow ptosis classification assigns a degree of ptosis to each interval, ranging from I to IV. Each degree was correlated with a numerical range in which > 1.8 cm is normal, 1.7-1.5 cm corresponds to degree I ptosis, 1.4-1.2 cm to degree II ptosis, 1.1-0.9 cm to degree III ptosis, and < 0.8 cm to degree IV ptosis. Surgery was indicated for degrees II, III, and IV. CONCLUSION: The objective measurement of brow tail position enabled classification of the degree of ptosis and guides surgical decision-making.

Surgical correction of myogenic ptosis using a modified levator resection technique.

OBJECTIVE: This report describes our experience using a modified anterior levator resection approach in myogenic ptosis patients and presents the results from a consecutive series of patients treated with this method. DESIGN: This was a retrospective case series study. PARTICIPANTS: Forty-one patients with moderate and severe myogenic ptosis were included. METHODS: All patients underwent a modified anterior levator resection approach under local anesthesia. The procedure involved exposing Whitnall's ligament, dissecting and resecting the underlying levator muscle from Whitnall's ligament, and leaving the aponeurosis intact. All patients underwent pre- and postoperative photography, and final outcomes were assessed after a minimum of 6 months. Outcome measures included pre- and post-marginal reflex distance (MRD1), symmetry of height, contour, and complications. RESULTS: Forty-one patients undergoing 56 procedures were included. The mean age of the patients was 15 (13-18) years. The mean postoperative MRD1 was 3.45 mm. Thirty-four patients achieved their desired lid height and contour, and 7 patients had undercorrection, including 1 patient with 2 mm of asymmetry, with a final success rate of 83% (34/41 patients). CONCLUSIONS: Our modified anterior levator resection approach had a high success rate and is particularly suitable for patients with moderate and severe myogenic ptosis.

Intrinsic and extrinsic risk factors for sagging eyelids.

IMPORTANCE: Sagging eyelids, or dermatochalasis, are a frequent concern in older adults. It is considered a feature of skin aging, but risk factors other than aging are largely unknown. OBJECTIVE: To study nongenetic and genetic risk factors for sagging eyelids. DESIGN: Upper eyelid sagging was graded in 4 categories of severity using digital photographs. Dermatochalasis was defined as the eyelid hanging over the eyelashes. Age, sex, skin color, tanning ability, hormonal status in women, current smoking, body mass index, and sun protection behavior were analyzed in a multivariable multinomial logistic regression model. Genetic predisposition was assessed using heritability analysis and a genome-wide association study. SETTING AND PARTICIPANTS: The study was performed in 2 independent population-based cohorts. The Rotterdam Study included older adults from one district in Rotterdam, the Netherlands, and the UK Adult Twin Registry (TwinsUK) included twins from all over the United Kingdom. Participants were 5578 unrelated Dutch Europeans (mean age, 67.1 years; 44.0% male) from the Rotterdam Study and 2186 twins (mean age, 53.1 years; 10.4% male) from the TwinsUK. MAIN OUTCOMES AND MEASURES: Sagging eyelid severity levels, ranging from 1 (normal control) to 4 (severe sagging). RESULTS: Among 5578 individuals from the Rotterdam Study, 17.8% showed dermatochalasis (moderate and severe sagging eyelids). Significant and independent risk factors for sagging eyelids included age, male sex, lighter skin color, and higher body mass index. In addition, current smoking was borderline significantly associated. Heritability of sagging eyelids was estimated to be 61% among 1052 twin pairs from the TwinsUK (15.6% showed dermatochalasis). A meta-analysis of genome-wide association study results from 5578 Rotterdam Study and 1053 TwinsUK participants showed a genome-wide significant recessive protective effect of the C allele of rs11876749 (P = 1.7 × 10(-8)). This variant is located close to TGIF1 (an inducer of transforming growth factor ß), which is a known gene associated with skin aging. CONCLUSIONS AND RELEVANCE: This is the first observational study to date demonstrating that other risk factors (male sex, genetic variants, lighter skin color, high body mass index, and possibly current smoking) in addition to aging are involved in the origin of sagging eyelids.

Surgical correction of blepharoptosis using a modified levator aponeurosis-Müller muscle complex reinsertion technique.

The purpose of this study was to evaluate the outcomes after ptosis correction surgery using a modified levator aponeurosis-Müller muscle complex reinsertion technique. In this clinical study, 75 eyelids of 49 patients with congenital blepharoptosis were treated with the modified technique. The results, including complications, were followed up and evaluated. Operation was performed via anterior transcutaneous incision. After separating the preseptal orbicularis oculi muscle, the levator complex, including Müller muscle and the levator aponeurosis, was visualized. The levator complex was cut into 2 parts at the top of the conjunctival fornix to create an upper portion and a lower portion. The detached lower portion of the complex flap combined with the tarsal plate was advanced superiorly and reinserted into the posterior aspect of the upper portion of the complex flap by using 3 horizontal mattress sutures. Preoperative ptosis severity was compared with the degree of ptosis correction using the Cochran-Mantel-Haenszel test. Preoperative levator function was compared with the degree of ptosis correction and the postoperative levator function using Fisher exact test for paired data. Sufficient postoperative correction of ptosis was achieved in 78.7% of eyelids. Postoperative levator function of more than 4 mm was achieved in 82.7% of all eyelids that underwent surgery. We conclude that the modified levator aponeurosis-Müller muscle complex reinsertion technique is effective for correcting congenital blepharoptosis, especially in patients with fair to good (>4 mm) preoperative levator function.

Relative incidence of blepharoptosis subtypes in an oculoplastics practice at a tertiary care center.

PURPOSE: In patients referred with blepharoptosis, the possibility of an underlying systemic cause for their ptosis can warrant a more detailed evaluation. The purpose of this study is to determine both the incidence and demographic characteristics associated with different types of ptosis in patients referred to the oculoplastics division at a tertiary care center. METHODS: A retrospective chart review was performed on all patients referred to the oculoplastics division between 2007 and 2010. Final etiology for each patient's ptosis was determined based on history, standard eyelid measurements, and ancillary testing. Based on etiology, ptosis was categorized as aponeurotic, neurogenic, myogenic, traumatic, congenital, or mechanical. Demographics, including median age and sex were analyzed for patients in each category of ptosis. RESULTS: Of the 251 patients, aponeurotic ptosis was the most common type of ptosis (60.2%), followed by traumatic (11.2%), congenital (10.4%), mechanical (8.8%), neurogenic (5.6%), and myogenic (4.0%). Of the neurogenic group, 35.7% of patients had cranial nerve 3 (CN 3) palsy, 28.6% had myasthenia gravis, 14.3% had aberrant regeneration, and 7.1% had Horner's syndrome. Thirty percent of the myogenic group had chronic progressive external ophthalmoplegia (CPEO). The congenital group had the youngest median age (10.5 years), yet the aponeurotic group had the oldest (62 years). CONCLUSIONS: A significant proportion of patients referred with ptosis had more serious conditions such as neurogenic or myogenic ptosis. Thus, clinicians should maintain a high degree of suspicion and thoroughly evaluate all patients with ptosis in order to properly assess for underlying systemic associations.

Impact of high myopia and duration of hard contact lens wear on the progression of ptosis.

PURPOSE: To investigate the impact of myopia and duration of hard contact lens (HCL) wear on the progression of ptosis. METHODS: This study involved 194 eyes of 98 patients with either bilateral or unilateral ptosis with long-term HCL wear. The ptosis of each eyelid was classified into 1 of 4 grades (no ptosis, mild, moderate and severe), and the average spherical equivalent refractive error (SERE), patient age and the duration of HCL wear were then examined. RESULTS: The average SERE (in diopters) in 99 severe eyes was -8.34, in 47 moderate eyes, -6.28, in 37 mild eyes -5.57 and in 11 no ptosis eyes, -4.80, while the average duration of HCL wear (in years) were 34, 30, 29, and 31, respectively. The average SERE was significantly higher in the severe than in the moderate, mild and no ptosis eyelids, and the average duration of HCL wear was significantly longer in the severe than in the moderate and mild ptosis eyelids. Path analysis showed that the severity of ptosis is significantly influenced by SERE, as well as by patient age and the duration of HCL wear. CONCLUSION: High myopia, patient age and long-term HCL wear are risk factors associated with the progression of ptosis.

A systematic review of comparison of upper eyelid involutional ptosis repair techniques: efficacy and complication rates.

BACKGROUND: The most common form of blepharoptosis is involutional ptosis, commonly caused by the effect of progressive age on the levator aponeurosis. The treatment for this acquired ptosis is strictly surgical. For the plastic surgeon, the ideal lid ptosis repair provides the longest efficacy, the fewest complications and revisions, and, ultimately, the highest functional and cosmetic outcome for the patient. With over 100 different described techniques, there exists a need to make a comparison. A systematic review is considered a higher level of evidence because it is a review designed to be reproducible, with predetermined inclusion and exclusion criteria. To date, there has been no systematic review to study the efficacy and complication rates between different involutional lid ptosis repair techniques. METHODS: A systematic search of the English literature published in the PubMed and Cochrane Central Register of Controlled Trials databases yielded trials on comparison of different adult upper lid involutional ptosis repair techniques regarding their efficacy and complication rates. Predetermined inclusion and exclusion criteria were used. RESULTS: : This systematic review revealed that there are no randomized, prospective, controlled comparison studies on involutional lid ptosis repair techniques. CONCLUSIONS: Although this systematic review revealed a lack of level I data in comparing the different ptosis repair techniques, it is important that the existing studies be reviewed and pooled to improve patient outcomes and to provide direction for future research. In the absence of higher level data studies, the authors propose a treatment algorithm for involutional ptosis repair. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Abordaje anterior versus posterior en la cirugía de la ptosis palpebral / Anterior vs posterior approach in palpebral ptosis surgery

La ptosis palpebral se define como la caída del párpado superior. Analizar los resultados obtenidos con su corrección quirúrgica y determinar la efectividad terapéutica con diferentes técnicas y vías de abordaje. Se realizó un estudio descriptivo, prospectivo y longitudinal con una casuística de 32 pacientes (50 ojos) operados de ptosis entre mayo de 2005 a marzo de 2006. La técnica y vía de abordaje quirúrgico que se aplicó la en cada caso, según el grado de severidad clínica (ligera moderada o severa) y su efectividad, se evaluó según la disminución en mm de la distancia margen-reflejo posoperatoria. Las técnicas quirúrgicas fueron: reforzamiento y reinserción de la aponeurosis, supramáxima, suspensión al frontal y abordaje posterior. La distancia margen-reflejo posoperatoria disminuyó de 1,2, 2,2 y 3,5 mm en ptosis ligeras moderadas y severas respectivamente. Si se selecciona adecuadamente la vía de abordaje, ambas aportan buenos resultados en la corrección de la ptosis(AU)

Palpebral ptosis is defined as the upper eyelid fall. To analyze the results of the surgical correction of palpebral ptosis and to determine its therapeutical effectiveness with various techniques and approach methods. A prospective, longitudinal and descriptive study was performed on 32 patients (50 eyes) operated on from ptosis covering May, 2005 through March, 2006. The surgical technique and approach method applied to each case, taking clinical severity into account (slight, moderate and severe), and their effectiveness were evaluated based on postoperative margin-reflex distance reduction in mm. The surgical techniques were reinforcement and reinsertion of aponeurosis, supramaxima, frontalis suspension and posterior approach. Postoperative margin-reflex distance was reduced by (1.2, 2.2 and 3.5 )mm in slight, moderate and severe ptosis respectively. The right selection of the surgical technique and the approach method helps in achieving good results in ptosis correction(AU)

Abordaje anterior versus posterior en la cirugía de la ptosis palpebral / Anterior vs posterior approach in palpebral ptosis surgery

La ptosis palpebral se define como la caída del párpado superior. Analizar los resultados obtenidos con su corrección quirúrgica y determinar la efectividad terapéutica con diferentes técnicas y vías de abordaje. Se realizó un estudio descriptivo, prospectivo y longitudinal con una casuística de 32 pacientes (50 ojos) operados de ptosis entre mayo de 2005 a marzo de 2006. La técnica y vía de abordaje quirúrgico que se aplicó la en cada caso, según el grado de severidad clínica (ligera moderada o severa) y su efectividad, se evaluó según la disminución en mm de la distancia margen-reflejo posoperatoria. Las técnicas quirúrgicas fueron: reforzamiento y reinserción de la aponeurosis, supramáxima, suspensión al frontal y abordaje posterior. La distancia margen-reflejo posoperatoria disminuyó de 1,2, 2,2 y 3,5 mm en ptosis ligeras moderadas y severas respectivamente. Si se selecciona adecuadamente la vía de abordaje, ambas aportan buenos resultados en la corrección de la ptosis.

Palpebral ptosis is defined as the upper eyelid fall. To analyze the results of the surgical correction of palpebral ptosis and to determine its therapeutical effectiveness with various techniques and approach methods. A prospective, longitudinal and descriptive study was performed on 32 patients (50 eyes) operated on from ptosis covering May, 2005 through March, 2006. The surgical technique and approach method applied to each case, taking clinical severity into account (slight, moderate and severe), and their effectiveness were evaluated based on postoperative margin-reflex distance reduction in mm. The surgical techniques were reinforcement and reinsertion of aponeurosis, supramaxima, frontalis suspension and posterior approach. Postoperative margin-reflex distance was reduced by (1.2, 2.2 and 3.5 )mm in slight, moderate and severe ptosis respectively. The right selection of the surgical technique and the approach method helps in achieving good results in ptosis correction.

A new ptosis correction technique: a modification of levator aponeurosis advancement.

There are many methods in ptosis surgery. These methods can be high or low in recurrence, and require a range of skill levels. In addition, there are many advantages to a procedure that may require much skill; while there are few advantages to some easy techniques. In our technique, not one disadvantage was seen. Eight patients with unilateral ptosis were corrected with modification of the Levator advancement procedure. Seven of the 8 patients achieved good results, with the correction within 1 mm of the opposite eyelid. Undercorrection was observed only in one patient. No other complications related to technique were seen. Levator advancement procedure is still an effective procedure but in this procedure, the major drawback is that the technique is irreversible. Remaining aponeurosis element is usually discarded and, because of it, re-correction in cases of under or overcorrection complications is not possible. This modified method is limited to this situation because there is no resection in levator aponeurosis. In addition, the technique is simple and safe. Eyelid lag on downgaze improves considerably over time, and the remaining asymmetry between the two eyelids is cosmetically acceptable to most patients.

[Classification and surgical management of upperlid dermatochalasis in middle-aged and elderly patients].

OBJECTIVE: To investigate the classification and surgical management of upper lid dematochalasis in middle-aged and elderly patients. METHODS: 105 cases with upper lid dermatochalasis who underwent surgical treatment between May, 2000 to May, 2005 were retrospectively analyzed. The dermatochalasis was classified according to eye brow position, bulge contour and the skin amount of upper lid. The post-operative cosmetic result was also assessed. RESULTS: Of the 105 treated cases, the post-operative cosmetic result was assessed as very satisfactory in 77 (87%) cases, as satisfactory in 11(10%) cases, and as dissatisfactory in 3 (2%) cases. CONCLUSIONS: Dermatochalasis in middle-aged and elderly patients has different types and should be treated with different surgical method.

Blepharoptosis: evaluation, techniques, and complications.

Blepharoptosis (ptosis) is one of the most common eyelid disorders encountered in ophthalmology. A detailed history and exam are crucial in the evaluation of a patient presenting with ptosis. This provides the correct guidelines for surgical planning. The appropriate surgical technique is usually determined by the degree of ptosis and levator function. The surgeon should have an armamentarium of several different techniques for the management of ptosis. This article will detail a modified approach to the traditional tarsomyectomy (Fasenalla-Servat procedure) and also discuss the levator advancement. Despite the proper preoperative evaluation and meticulous attention to technique, the ptosis surgeon may still encounter postoperative complications. The ability to manage the array of possible complications truly distinguishes the ptosis surgeon.

Palpebral ptosis: clinical classification, differential diagnosis, and surgical guidelines: an overview.

Palpebral ptosis indicates the abnormal drooping of the upper lid, caused by partial or total reduction in levator muscle function. It may be caused by various pathologies, both congenital and acquired. Based on a review of the available literature and on our own clinical experience, a classification is proposed as well as a differential diagnosis between ptosis and pseudoptosis. Some basic surgical guidelines related to age of onset and etiopathogenesis are drawn. Ptosis is divided into neurogenic, myogenic, aponeurotic, and mechanical. The aim of surgery is two fold: functional, to correct the limit in the visual field; and also aesthetic. From January 2000 to January 2004, 42 patients were referred and treated at the Unit of Cranio-Maxillofacial Surgery-Centre for Orbital Pathology and Surgery, Hospital and University, Ferrara, Italy. Of these, 12 cases were congenital and 30 acquired (13 were monolateral and 29 bilateral, for a total of 71 cases). The most widely used surgical techniques were levator muscle recession and frontalis suspension. In congenital forms, these techniques were often associated with techniques to correct oculo-muscular imbalance (i.e., strabismus).Seventy-one upper eyelids were treated, 5 of which were mild, 35 moderate, and 31 severe. Regarding levator muscle function, 60 were fair and 11 poor.Surgical treatment followed the indications and timing with good morphologic and aesthetic results. Complications included two cases of hypocorrection, two asymmetries, and two cases of hypercorrection. Surgical treatment of palpebral ptosis is complex and requires precise diagnosis and indications for surgery related to clinical examination and pathogenesis. Even if these indications are strictly followed, in some cases, the outcomes are unpredictable.

Blepharoptosis correction.

Blepharoptosis is a common complaint of eyelid malposition in which the upper eyelid is lower than normal. There are multiple types of blepharoptosis based on cause, and important studies have recently been published on one type, myogenic blepharoptosis. There have classically been three methods for correcting blepharoptosis. For the most severe cases, frontalis slings are often performed. New materials, such as polyester mesh, have shown promise as alternatives in forming frontalis slings. A recent paper has suggested a new algorithm for another method of blepharoptosis correction, the conjunctiva-Müller muscle resection. The effectiveness of the third type of procedure for blepharoptosis correction, the external levator advancement, has been reinforced in a study examining the procedure in cases of congenital blepharoptosis.

[Familial chronic progressive blepharoptosis without other neurological symptoms: a new clinical entity?].

Nine patients over 5 generations developed progressive bilateral blepharoptosis from 40 to 50 years of age, suggesting that they had an autosomal dominantly inherited blepharoptosis. Except for the ptosis, they had no apparent neurological symptoms: normal ocular movement, no bulbar sign and no muscle weakness in the extremities. On laboratory examination, serum creatine kinase and blood lactate levels were within normal limits, and acetylcholine receptor antibody was not elevated. Electrophysiological studies including EMG and nerve conduction velocities were normal. Muscle biopsies from gastrocnemius and palpebral muscles were nondiagnostic with no ragged-red fibers nor rimmed vacuoles. Nuclear inclusions were not recognized by electron microscopy. Since none of patients examined had mitochondrial DNA deletions and GCG repeat expansion in the poly A binding protein P2 (PABP2) gene, this familial disorder is a unique blepharoptosis with no relationship to progressive external ophthalmoplegia or oculopharyngeal muscular dystrophy with PABP2 mutation.

Aponeurotic repair of involutional blepharoptosis.

Thirty-two patients with involutional blepharoptosis were treated by reattachment of the levator aponeurosis and followed up for a minimum of one year. The median age of the patients was 68 years and they were predominantly female and had bilateral ptosis. Seven (22%) needed revisional surgery because of undercorrection. Results were evaluated using scoring from 1-4 where 1 is normal, 2 mild ptosis, 3 moderate ptosis, and 4 severe ptosis. After one operation the degree of ptosis improved from 3.2 to 1.3. Half the patients had simultaneous procedures, usually blepharoplasty, but the mean duration of operation was still only 34 minutes (range 15-77). The recovery period was short and complication rate low.