Surgical Management of Overgrowth Syndrome With Bilateral Vision-Threatening Ptosis.

We describe the first case reported in ophthalmological literature of the surgical management of a 17-month-old boy with bilateral vision-threatening ptosis, tarsomegaly, ectropion, and euryblepharon secondary to suspected overgrowth syndrome. We elaborate on the major challenges associated with surgical management including the natural and asymmetric growth of oversized tissue, the high likelihood of scarring and formation of disorganized tissue, and risks of frequent intubation in these patients who may have lesions that compromise critical structures such as the airway. Ultimately, surgical intervention is encouraged primarily if vision or ocular health is threatened and secondarily to achieve good cosmesis.

Effect of Tranexamic Acid on Intra- and Postoperative Bleeding in Eyelid Surgery: A Prospective, Randomized, Multicenter, Double-Masked, Control Trial.

PURPOSE: Pilot studies suggest that waiting 15 minutes after a subcutaneous tranexamic acid injection is associated with decreased intraoperative bleeding and postoperative ecchymosis in eyelid surgery. The outcomes of commencing eyelid surgery immediately after injection without a waiting period remain unexplored. METHODS: This prospective, randomized, multicenter, double-masked, controlled study examined bilateral symmetric upper and/or lower lid blepharoplasty or ptosis repair. Patients received tranexamic acid in 1 eyelid and control in the contralateral eyelid. The surgeon recorded the side with more intraoperative bleeding. Two masked graders evaluated periocular ecchymosis at postoperative day 0 and postoperative week 1 (POW 1) with a 5-point scale. At POW 1, patients reported subjective grading of bruising as increased on 1 side or similar on both sides. Results were analyzed with Wilcoxon signed-rank and sign tests. RESULTS: Of 130 patients, there was less eyelid ecchymosis on the tranexamic side at postoperative day 0 ( p = 0.001) and POW 1 ( p < 0.001). By surgery type, the 69 levator advancement surgeries had significantly less ecchymosis at postoperative day 0 ( p < 0.001) and POW 1 ( p = 0.001), while upper eyelid blepharoplasty, combined upper and lower lid blepharoplasty, and conjunctivomullerectomy trended toward significance. Of 68 patients reporting a POW 1 grading, 69% reported less bruising on the tranexamic side ( p < 0.001). Intraoperative bleeding was not significantly different between sides ( p = 0.930). CONCLUSIONS: Without a postinjection waiting period, subcutaneous tranexamic acid for eyelid surgery significantly decreased postoperative ecchymosis on postoperative day 0 and POW 1 but did not affect intraoperative bleeding. Subcutaneous tranexamic acid was not associated with any complications.

Head rotation and the perception of eyelid height and contour.

PURPOSE: Effective visual perceptual processing is one of the many components of surgical competence. Human face identification is most efficient when viewed upright. However, it is not yet clear how this perception sensitivity impacts eyelid symmetry. This study investigates surgeons' and laypeople's accuracy and efficiency in perceiving eyelid asymmetry from different spatial perspectives. METHODS: A prospective psychometric experiment was conducted where oculoplastic surgeons were recruited from the American Society of Ophthalmic Plastic and Reconstructive Surgery and the Brazilian Oculoplastic Surgery Society, and control participants were recruited via crowdsourcing (Amazon's Mechanical Turk). Standard illustrations of the human face with varying degrees of eyelid abnormality, laterality, gender and rotation were presented to participants who were asked to judge whether the eyelids were symmetric or asymmetric. RESULTS: The survey was completed by 75 oculoplastic surgeons (49.33% male; mean age of 46.9±10.7) and 192 lay individuals (54.6% male; mean age 34.6±11.3 years). Among oculoplastic surgeons, deviation from upright was significantly associated with increased reaction time and decreased proportion correct (OR per 45° for peak 0.68, 95% CI 0.60 to 0.77, p<0.001; OR per 45° for ptosis 0.52, 95% CI 0.32 to 0.87, p=0.012; OR per 180° for aggregate responses 0.56, 95% CI 0.51 to 0.61, p<0.001). Oculoplastic surgeons demonstrated increasing accuracy and decreasing reaction time with additional trials for both peak and ptosis. CONCLUSION: Oculoplastic surgeons perceive eyelid asymmetries more accurately and can better compensate for inverted sensory information. However, accuracy increases and reaction time decreases with additional trials, suggesting trainability and potential for improvement in inversion disability.

Digital analysis of unilateral ptosis repair: external levator advancement vs. Müller's muscle conjunctival resection.

PURPOSE: Evaluation of lid contour and marginal peak point changes to compare outcomes of external levator advancement and Miiller's muscle conjunctival resection surgery in unilateral ptosis. METHODS: We reviewed the charts of unilateral ptosis patients who underwent external levator advancement or Miiller's muscle conjunctival resection. Eyelid contour analysis was conducted on preoperative and 6-month postoperative digital images. This was performed with the multiple margin reflex distances technique, measuring the vertical distance from a line intersecting the center of the pupil to the eyelid margin at 10 positions at 2 mm intervals. The marginal peak point changes were analyzed digitally using the coordinates of the peak point according to the pupil center. Each position's mean distance was compared preoperatively, postoperatively, and with the fellow eyelid. RESULTS: Sixteen patients underwent external levator advancement and 16 patients had Miiller's muscle conjunctival resection. The mean margin reflex distance was improved by both techniques (1.46 vs. 2.43 mm and 1.12 vs. 2.25 mm, p=0.008 and p=0.0001 respectively) and approached that of the fellow eyelid (2.43 vs. 2.88 and 2.25 vs. 2.58 mm, p=0.23 and p=0.19, respectively). However, statistically significant lid margin elevation was limited to between the N6 and T6 points in the external levator advancement group. Whereas, significant elevation was achieved along the whole lid margin in the Miiller's muscle conjunctival resection group. The marginal peak point was shifted slightly laterally in the external levator advancement group (p=0.11). CONCLUSIONS: Both techniques provide effective lid elevation, however, the external levator advancement's effect lessens toward the canthi while Müller's muscle conjunctival resection provides more uniform elevation across the lid margin. The margin reflex distance alone is not sufficient to reflect contour changes.

Congenital ptosis with aponeurotic maldevelopment: clinical and surgical perspectives : Aponeurotic maldevelopment in congenital ptosis.

PURPOSE: Levator muscle dystrophy has been commonly accused being the main pathology of congenital ptosis, nevertheless, few reports drew attention to the existence of congenital aponeurotic defects. This study aims at highlighting the detailed clinical and surgical features of aponeurotic maldevelopment together with the efficacy of simple aponeurosis repair. METHODS: This is a retrospective nonrandomised study including patients with congenital ptosis who underwent levator muscle surgery throughout 4 years. Patients' records were reviewed for the preoperative clinical assessment and photographs, intraoperative recorded data, and videos as well as postoperative data and photographs. RESULTS: Twenty-seven eyes of 22 patients (9.4%) out of 287 eyes were recorded to have absent levator muscle at its typical anatomical insertion site intraoperatively. The mean preoperative MRD1 was (0.44 ± 1.17 mm). The mean levator function was 8.56 ± 3.89 mm, with higher-than-normal crease position (mean value 10.07 ± 1.62 mm). 25 eyes of included cases (92.6%) showed total absence of the levator aponeurosis edge which only was revealed after cutting through the orbital septal covering of the preaponeurotic fat. CONCLUSION: Congenital aponeurotic defect is an established yet under reported entity of congenital ptosis with reproducible characteristic intraoperative findings. Simple aponeurosis repair could achieve ptosis correction in such cases.

Sling for the sling: a new technique for long-term correction of severe congenital ptosis.

INTRODUCTION: Severe congenital ptosis poses a complex challenge for oculoplastic surgeons, requiring meticulous surgical intervention to restore eyelid function and improve aesthetic outcomes mainly by using frontalis sling approach. A crucial issue in frontalis sling surgeries is the sustainability of effect. PURPOSE: This retrospective study reports the outcomes of two surgical techniques for treating severe congenital ptosis in the paediatric age group: Silicon rods ptosis sling and a novel technique involving the use of Silicon rods with green braided polyester (Ethibond) sutures to secure the rods in place "sling for the sling". METHODS: The medical records of children who underwent frontalis suspension were reviewed in a retrospective fashion. We identified two groups; the first group (20 patients: 35 eyelids) had the traditional frontalis suspension surgery using silicone suspension set, the second group (14 patients: 25 eyelids) was operated using the new "sling for sling" technique. We used the postoperative marginal reflex distance-1 (MRD-1) as the primary outcome measure while the frequency of both wound related complications and recurrence were considered as secondary outcome measures. Post operative data were collected and compared after 1 month, 6 months, 12 months, and 18 months. RESULTS: Preliminary results indicate promising outcomes for both techniques, with significant improvement in eyelid elevation observed in both groups. However, the novel technique using Silicon rods with Ethibond sutures demonstrated enhanced sustainability, leading to a more durable outcome with significantly less recurrence. CONCLUSION: This study highlights the potential benefits of the novel technique in treating severe congenital ptosis and introduces an innovative approach to Silicone rods fixation to achieve a long-term corrective effect.

A Systematic Quality Assessment of Online Resources on Eyelid Ptosis Using the Modified Ensuring Quality Information for Patients (mEQIP) Tool.

BACKGROUND: Eyelid ptosis is an underestimated pathology deeply affecting patients' quality of life. Internet has increasingly become the major source of information regarding health care, and patients often browse on websites to acquire an initial knowledge on the subject. However, there is lack of data concerning the quality of available information focusing on the eyelid ptosis and its treatment. We systematically evaluated online information quality on eyelid ptosis by using the "Ensuring Quality Information for Patients" (EQIP) scale. MATERIALS AND METHODS: Google, Yahoo and Bing have been searched for the keywords "Eyelid ptosis," "Eyelid ptosis surgery" and "Blepharoptosis." The first 50 hits were included, evaluating the quality of information with the expanded EQIP tool. Websites in English and intended for general non-medical public use were included. Irrelevant documents, videos, pictures, blogs and articles with no access were excluded. RESULTS: Out of 138 eligible websites, 79 (57,7%) addressed more than 20 EQIP items, with an overall median score of 20,2. Only 2% discussed procedure complication rates. The majority fail to disclose severe complications and quantifying risks, fewer than 18% clarified the potential need for additional treatments. Surgical procedure details were lacking, and there was insufficient information about pre-/postoperative precautions for patients. Currently, online quality information has not improved since COVID-19 pandemic. CONCLUSIONS: This study highlights the urgent requirement for improved patient-oriented websites adhering to international standards for plastic and oculoplastic surgery. Healthcare providers should effectively guide their patients in finding trustworthy and reliable eyelid ptosis correction information. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A new technique to prevent conjunctival prolapse in Asian patients for correcting severe blepharoptosis.

BACKGROUND: In Asian patients with severe ptosis,the use of conjoint fascia sheath (CFS) suspension or levator aponeurosis fascia complex shortening surgery can correct the ptosis. During these surgery, a significant amount of levator aponeurosis fascia shortening is performed, which often leads to serious complications such as conjunctival prolapse.This study compares two surgical approaches for correcting severe blepharoptosis:Conjoint fascial sheath (CFS) + levator aponeurosis and muller's muscle complex (LM complex) suspension and conjoint fascial sheath (CFS) + LM complex+conjunctival suspension.The postoperative efficacy and the incidence of complications such as conjunctival prolapse are investigated for both procedures. METHODS: This study retrospectively analyzed 70 patients (77eyes) with severe blepharoptosis from January 2019 to December 2021. The patients were divided into the experimental group (34 cases, 38 eyes) and the control group (36 cases, 39 eyes). The experimental group was treated with CFS+LM complex + conjunctival suspension, and the control group was treated with CFS+LM complex suspension.The curative effect of blepharoptosis, the incidence of complications such as conjunctival prolapse and patient satisfaction were compared between the two different surgical methods. RESULTS: There was no significant difference in the correction effective rate between the experimental group (84.21%) and the control group (82.05%) (P > 0.05). There was no significant difference in the total incidence of complications between the experimental group (23.68%) and the control group (38.46%) (P > 0.05), but in the complication of conjunctival prolapse, the incidence of conjunctival prolapse in the experimental group was significantly lower than that in the control group. The difference was statistically significant (P < 0.05). In the survey of patient satisfaction rate, the satisfaction rate of the experimental group was significantly higher than that of the control group,which was statistically significant (P < 0.05). CONCLUSIONS: Compared to CFS+LM complex suspension surgery, the CFS+LM complex + conjunctival suspension has a definite effect in preventing postoperative conjunctival prolapse .The procedure has a high feasibility, good corrective effect, and improves patient satisfaction after surgery.

How to assess blepharoptosis via telemedicine: method and its reliability.

PURPOSE: To report the method to assess belpahroptosis and its reliability of adult ptosis using video consultation. METHODS: This is a retrospective, comparative, case series. The surgical waiting list for ptosis surgery between 8/2020 and 1/2021 was checked and only cases listed for surgery via video consultation assessment, without any previous face-to-face consultation, were included. The following data were collected for patients who underwent video consultation before surgery: Demographic data, level of experience of clinician, levator function, Cogan's twitch sign, fatigability test, eye motility, presence of lagophthalmos, clinical history to rule out Myasthenia Gravis, other myopathies or Horner syndrome, whether the surgery was performed or canceled, reason for cancellation, date of surgery, type of procedure and surgeon experience. RESULTS: A total of 176 patients underwent ptosis surgery. From those, 45 patients (25.6%) had only video assessment prior to surgery, 36 patients (80%) eventually underwent ptosis surgery. Surgery was canceled in 20% of the cases: in 2 cases (4.44%) due to misdiagnosis of ptosis during video consultation, confirmed on the day of surgery during pre-surgical face-to-face assessment; the other 7 cases (15.55%) belpharoptosis was confirmed on face-to-face examination but the surgery was canceled due to other reasons. The diagnosis of ptosis assessment via video consultation was corrected in 43 cases (95%) (p_value = 0.156, chi_ square). The accuracy of ptosis diagnosis was 13 out of 15 (86.7%) by fellow assessments and 30 out of 30 (100%) by consultant assessments (p_value = 0.041, chi_ square). In most of the cases ptosis assessment in video consultation included: rough judgment of levator function, eye motility and checking signs of lagophthalmos. CONCLUSIONS: Video consultation is an efficient and reliable way to assess patients with ptosis, with 95% of reliability. Although a thorough ptosis assessment is advised, there was no difference between the accuracy of diagnosis on those who did not have the full suggested assessment.

Use of autogenous fascia lata slings in the surgical correction of ptosis: a systematic review of the literature and meta-analysis.

Ptosis is an abnormally low-positioned upper eyelid. Management depends on severity, aetiology, and function of the levator palpebrae superioris muscle (LPS). This review evaluates the success of autogenous fascia lata slings (AFLS) in the surgical management of ptosis, together with complication and reoperation/revision rates. A literature search was conducted on PubMed, Google Scholar PROSPERO, Dynamed, DARE, EMBASE, Cochrane, and BMJ databases (PROSPERO registration: CRD42023475090), and 30 studies (3690 patients and 5059 eyes) were included. The average age of the patients was 14.2 years with a ratio of male:female patients of 1:0.7. A total of 2532 eyes had undergone a fascial sling with autogenous fascia lata. The average follow-up period was 32.6 months. Improvement in the margin to reflex distance 1 (MRD1) with fascial sling surgery was 2.79 mm. The rate of complications from surgery involving autogenous fascia lata was 21.3%. The most common complications included lagophthalmos (19.8%), residual ptosis (11.5%), and corneal damage (10.4%). The reoperation rate was 13.4%. Most common indications for reoperation were cosmetic, with asymmetry (18%), lid crease abnormalities (30%), and upper eyelid trimming (18%). The overall complication rate in AFLS patients was 20% (95% CI: 6 to 35, p < 0.01; I2 = 89%) versus 27% (95% CI: 14 to 40, p < 0.01; I2 = 90%) in non-AFLS patients. AFLSs are prudent in the surgical management of ptosis. The results of this review demonstrate that their use is associated with similar complication rates but fewer reoperations than other traditional techniques.

The Long-Term Effect on Dry Eye of Posterior Approach Ptosis Surgery Vs. Upper Eyelid Blepharoplasty.

PURPOSE: To examine the long-term effect of combined blepharoplasty and Müller muscle-conjunctival resection (MMCR) compared to an upper blepharoplasty procedure on dry eye syndrome. METHODS: This is a Prospective comparative case series. Two groups of patients participated in this study: the blepharoplasty group included adult patients that underwent blepharoplasty at least 3 years earlier and the ptosis group consisting of adult patients that underwent MMCR with blepharoplasty at least 3 years earlier. The parameters that were compared for all patients before the procedure, on postoperative day 90, and at the long-term follow-up were: Schirmer-test 2, tear break-up time (TBUT), fluorescein staining, and lissamine green (LG) staining. RESULTS: The participants included 25 post-MMCR patients with a mean follow-up of 4.94 ± 0.64 years and 15 post-blepharoplasty patients with a mean follow-up of 4.22 ± 0.32 years. There was a significant increase in the postoperative LG and fluorescein staining scores compared to the preoperative scores in the ptosis group (p < .01 and p < .01, respectively) as well as a decrease in postoperative TBUT compared to the preoperative values (p = .044). Those parameters were not significant in the blepharoplasty group. CONCLUSIONS: Patients who underwent MMCR, but not those following upper blepharoplasty, showed signs of dry eye compared to the preoperative status after long-term follow-up. Dry eye signs should be examined before MMCR surgery, and patients should be aware of the high risk of developing dry eye and the need for long-term treatment. Surgeons should carefully consider performing MMCR for patients with severe dry eye.

Outcomes of a novel algorithm for levator muscle plication surgery in congenital blepharoptosis.

AIM: to assess the outcomes of a novel algorithm for the calculation of the amount levator muscle plication in congenital blepharoptosis surgery. METHODS: this retrospective comparative study included 34 patients with congenital ptosis subjected to levator muscle plication surgery during the period from October 2021 to November 2022. They were divided into two groups. Group A: the amount of levator muscle plication was calculated by a traditional formula [(amount of ptosis x 3) + 9 mm in cases with good levator function or (amount of ptosis x 3) + 11 mm in cases with fair levator function]. Group B: the amount of levator muscle plication was calculated by a novel nomogram [the result of the traditional formula was modified by subtracting 4 mm if the calculated amount was ≥ 15 mm or subtracting 3 mm if the calculated amount was < 15 mm]. Demographic data, baseline ptosis characteristics and postoperative results at 1st week, 1st month, 3rd month and 6th month were compared between the groups. Primary outcome measure was postoperative Marginal Reflex Distance (MRD1). Secondary outcome measures were lid contour, lid crease and any reported complications. RESULTS: Group A included 20 eyes of 18 patients while Group B included 20 eyes of 16 patients. The mean amount of levator muscle plication was 16.98 ± 2.44 mm and 13.48 ± 2.42 mm in group A and group B respectively. The difference between the two groups was highly statistically significant (p < 0.001). Mean MRD1 at the 1st postoperative week was 4.95 ± 0.37 mm in group A and 4.08 ± 0.64 mm in group B. This difference was highly statistically significant (P < 0.001). Overcorrection was seen in 8 (40%) eyes in group A and 1 (5%) eye in group B. The difference was statistically significant between the two groups (p = 0.008). Undercorrection was seen in only 1 (5%) eye in group B. No other complications were reported. Surgical success was achieved in 12 (60%) eyes in group A versus 18 (90%) eyes in group B. The difference between the two groups was statistically significant (p = 0.03). CONCLUSION: our novel nomogram for the calculation of the amount levator muscle plication in congenital blepharoptosis surgery is effective in achieving a satisfactory postoperative MRD1.

A new algorithm for the transconjunctival correction of moderate to severe upper eyelid ptosis in adults.

A posterior approach is recommended for the correction of mild to moderate upper eyelid ptosis in adults. The aim of this study is to propose a new algorithm that helps to predict outcomes in the transconjunctival correction of moderate to severe blepharoptosis. This study included adult patients with moderate to severe upper eyelid ptosis treated between 2019 and 2021. Patients meeting inclusion criteria underwent ptosis correction through a posterior approach using an algorithm: 4 mm Mueller's muscle transconjunctival resection to correct 1 mm ptosis (depending on a test with 10% phenylephrine: 3-12 mm) ± tarsal plate resection: 1 mm for every 1 mm of residual ptosis after phenylephrine test, but leaving a minimum of 4 mm upper tarsus intact. Outcomes were ovserved within at least 6-months. Outcomes were assessed based on pre- and postoperative MRD1 changes, inter-eyelid height symmetry, cosmetic effect, and complications. Outcomes of 118 procedures in 81 patients (average age 69, range: 47-87) were analyzed. MRD1 changes were statistically significant, from 0.2 ± 1.6 mm before to 4.1 ± 1 mm after surgery. The function of the levator palpebrae superioris muscle was 10.2 ± 3.4 (range 5-17) mm. Upper eyelid lifted by an average of 1.8 ± 0.7 (range 0-3) mm after the instillation of 10% phenylephrine eyedrops. An average of 8.5 ± 0.8 (range 8-10) mm of conjunctiva and Mueller's muscle and 2.2 ± 0.9 (range 1-5) mm of the tarsal plate were resected during the procedure. Inter-eyelid height symmetry within 1 mm was achieved in 95% of outcomes. The algorithm introduced in this study appears to be useful to achieve repeatable satisfactory outcomes in the transconjunctival correction of moderate to severe upper eyelid ptosis in adults with at least "fair" levator function.

A simplified technique for correction of complete ptosis secondary to palpebral neurofibromatosis.

PURPOSE: To present a simplified technique in management of complete ptosis secondary to neurofibromatosis. METHODS: This prospective, non-comparative, clinical interventional study included 13 patients with complete ptosis secondary to histologically proved plexiform neurofibromas. It was conducted at the Orbital Unit of Assiut University Hospital, the referral center of Upper Egypt in the period between June 2013 and October 2021. In all cases, a simplified technique of 5 surgical steps was applied: (A) Division of the involved eyelid surgically into three parts by drawing 2 curvilinear lines, the superior line 11 mm below and parallel to the lower eyebrow hairline and the inferior one 10 mm above the lid margin, (B) Resection (full-thickness) of the large middle part which involves the main pathology and lies between the 2 lines, (C) Preservation of the upper part with identification, dissection and clamping of the levator muscle, (D) Refinement of the lower part by removal of any tissue between the skin and the debulked tarsus and (E) Re-suturing of the upper and lower parts in layers; conjunctiva to conjunctiva, levator to tarsus (after resection of a part that corrects the ptosis) and skin to skin. RESULTS: Ptosis was completely corrected in 8 cases (61.5%) and residual mild ptosis occurred in 5 patients (38.5%). No exposure keratopathy or tumor growth was reported during the follow-up period of minimum 1 year. CONCLUSIONS: This simplified technique could be considered as a surgical basis for correction of complete ptosis in neurofibromatosis.

Marcus-Gunn jaw winking syndrome: case series study and management algorithm.

PURPOSE: To identify a rationale for treatment of patients with Marcus Gunn jaw winking syndrome (MGJWS). METHODS: Retrospective review of 38 consecutive patients with MGJWS referred to a single tertiary institution. Clinical data included visual acuity, ocular motility, side of jaw-wink, presence or absence of ptosis, levator function, clinical photographs, and management undertaken. Thirty-two patients were operated on with customized surgery by a senior surgeon (FQL). RESULTS: Cases with no ptosis or mild ptosis were managed conservatively. Levator advancement (LA) was successful in case of moderate ptosis and negligible synkynesis but resulted in a more evident synkinesis. Levator resection (LR) in patients with severe ptosis was associated with high rate of ptosis recurrence. Ptosis was adequately corrected in all patients submitted to uni- or bilateral levator excision (LE) and bilateral frontalis suspension (FS) or unilateral frontalis flap (FF). Jaw winking resolved in all patients submitted to LE but recurred in three cases at a later stage. Strabismus surgery was performed simultaneously in case of associated esotropia or hypotropia. CONCLUSIONS: Moderate ptosis can be corrected with LA, but success is not related to levator function and synkinesis becomes more evident postoperatively. In severe ptosis, LR showed unpredictable results. In case of severe ptosis and severe synkinesis, uni- or bilateral LE and bilateral FS are recommended; unilateral FF is an alternative in patients who refuse bilateral treatment, as the cosmetic outcome is usually better than after unilateral FS.

Key Roles of Conjunctiva Fornix-Bulbar Conjunctiva-Tenon Capsule in Conjoint Fascial Sheath Suspension.

BACKGROUND: Bulbar conjunctival prolapse is one of the complications of conjoint fascial sheath (CFS) suspension and has a negative impact on surgical results. To explore the prevention methods of this complication, the authors compared the incidence of it between the below-conjunctiva fornix-bulbar conjunctiva-Tenon capsule (CBT) approach and the above-CBT approach to dissecting CFS in CFS suspension and shared their experience in the treatment of bulbar conjunctival prolapse. METHODS: From January of 2020 to August of 2021, 81 patients with severe congenital ptosis who underwent CFS suspension were enrolled and divided into two groups. Forty-five patients' (group A) CFS was dissected by means of the below-CBT approach and 36 patients' (group B) CFS was dissected by means of the above-CBT approach. Data regarding the incidence and outcomes of bulbar conjunctival prolapse and the postoperative condition were collected and analyzed. RESULTS: The incidence of bulbar conjunctival prolapse was 24.44% in group A and 2.78% in group B. Of the 12 bulbar conjunctival prolapse patients, seven patients' conditions improved after conservative treatment, and five did not. All of them underwent bulbar conjunctiva resection within 1 year and were cured. No recurrent prolapse was observed within 3 months postoperatively. At the last follow-up, the mean marginal reflex distance 1 and palpebral fissure height were 4.09 ± 0.19 mm and 9.85 ± 0.62 mm, respectively. There were no complications except lagophthalmos (16 eyelids), asymmetric eyelid contour (one patient), and trichiasis (two eyelids). CONCLUSIONS: The incidence of bulbar conjunctival prolapse decreased significantly by dissecting CFS by means of the above-CBT approach. For patients with bulbar conjunctival prolapse after CFS suspension, bulbar conjunctiva resection could provide satisfactory results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Whitnall Barrier: A Technique for the Management of Lacrimal Gland Prolapse.

BACKGROUND: The Whitnall barrier procedure, a modified Beer and Kompatscher surgical technique to reposition the lacrimal gland, is presented alongside a case series of patients demonstrating excellent aesthetic and functional outcomes. METHODS: The Whitnall barrier procedure is illustrated procedurally and accompanied by a case series of 20 consecutive patients treated in a single institution by a single surgical team between December of 2016 and February of 2020. Lid contour and function were assessed postoperatively, as was patient satisfaction. RESULTS: Thirty-seven eyes of 20 patients were included. All patients were women, with an average age of 50 years. Fourteen patients underwent surgery for cosmesis, four had inactive thyroid eye disease, and two had lacrimal gland enlargement secondary to dacryoadenitis. The degree of lacrimal gland prolapse was described as mild in two eyes and moderate in 35 eyes. All patients had one or more additional surgical procedures. Mean follow-up duration was 11 months, with complete resolution of lacrimal gland prolapse in 34 eyes. The patient who did not have complete resolution had dacryoadenitis and required ongoing immunosuppressive therapy. Two patients were discharged on topical lubricants: one with thyroid eye disease and one cosmetic patient who underwent upper and lower lid blepharoplasties at the same time. There were no intraoperative complications and no incidences of infection, dehiscence, or damage to the lacrimal gland ductules. CONCLUSIONS: The Whitnall barrier technique is a safe and effective surgical procedure to restore the anatomic location of the lacrimal gland. It provides excellent aesthetic and functional outcomes.