Simplification in locating and dissecting the levator muscle of the upper eyelid in surgery for ptosis

BACKGROUND: While repairing eyelid ptosis by aponeurotic resection by anterior approach, the risk of damaging the levator complex and the conjunctiva is significant. In order to simplify the dissection between Müller's muscle and the underneath conjunctiva, we use a modification of the usual surgical technique. METHODS: Before the skin incision, the eversion of the upper eyelid allows to dissect the conjunctiva from the Müller's muscle under direct visual control, starting from the upper tarsal margin. A silicone band is then passed through the so created horizontal subconjunctival tunnel. The upper eyelid can be physiologically replaced, and the levator muscle aponeurosis exposed. The two ends of the band are then pulled on surface through two lateral incision performed close to the upper tarsal edge. Now the band plays the role of a useful landmark: every tissue above the band is levator complex; when stretched downwards, it points the upper edge of the tarsal plate. We operated by this technique 24 eyes, affected of acquired or congenital ptosis. Fourteen eyelids had already undergone ptosis surgery elsewhere. RESULTS: We achieved good-to-excellent results in all cases, without any important postoperative complications. CONCLUSIONS: The proposed manoeuvre makes easier the dissection of the inner aspect of the levator complex, because of the material control. Therefore it minimises the tissue trauma and the postoperative complications, particularly in complicated cases characterised by scarring and fibrosis.     

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The method of multilevel full-thickness eyelid resection combined with plication of the levator aponeurosis Müller's muscle was used to correct severe acquired ptosis. The 19 eyes of 13 patients treated with this method included neurogenic ptosis (3 eyes of 3 cases), myasthenia gravis ptosis (8 eyes of 4 cases), chronic progressive external ophthalmoplegia (4 eyes of 2 cases) and traumatic ptosis (4 eyes of 4 cases). All the patients had poor levator function. After operation their eyelids were elevated to an acceptable functional level without exposure keratopathy. The operative results were satisfactory. The operation procedure and indications were discussed.     

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Preoperative electromyographic examinations of superior levator muscle were done in 36 ptotic patients using the Neurematic 2000 electromyograph. Shortening of the levator palpebrae superior was done through a combined internal and external route. In 12 patients of mild ptosis the spike voltage was all above 30 mv during contraction. When the spike voltage was above 100 mv, better operative results were obtained. In 24 patients whose ptosis was moderate or severe, the graphs of contraction generally showed simple phases with low amplitude. In 9 patients whose spike voltage was below 30 mv, their palpebral fissure did not reach the anticipated width after the operation. On the contrary, in 15 patients whose spike voltage was above 30 mv the operative results were satisfactory. It is concluded that in patients whose ptosis is moderate or severe, the operative procedure should be based on electromyographic examinations. If the spike voltage of the superior levator muscls is higher than 30 mv on contraction, simple shortening of the levator will be successful. If the spike voltage is lower than 30 mv and the graph presents simple phase or electro-tranquilization, then suspension of the frontalis muscle is preferable.     

The effect of catalase inhibitor 3-amino-1,2,4-triazole on coupled oxidative phosphorylation and the state of adenyl system in liver mitochondria of albino rats

Blepharoptosis is a recognized complication of cataract extraction and other ocular procedures. A 6-month waiting period is recommended before repairing postcataract ptosis because most cases resolve during this time. We report the course of a patient who developed spontaneous recovery of eyelid function 11 months after cataract surgery. She had previously undergone successful ptosis repair 8 months after cataract extraction, but developed overcorrection 3 months later as her levator function returned to normal. We recommend at least a 1-year waiting period before repair of postcataract ptosis. If corrective surgery is undertaken earlier than 1 year due to visual obstruction or for aesthetic reasons, we suggest two guidelines. The levator should be plicated rather than resected and patients should be forewarned of the possibility for a revisionary procedure if spontaneous return of levator function occurs.     

Regeneration of adrenal cortical tissue after adrenal autotransplantation

OBJECTIVE: This study examined the muscle fiber type distribution within the normal adult levator veli palatini muscle. METHODS: Levator veli palatini muscle tissue was harvested from the palates of 12 (seven female, five male) adult noncleft cadavers. Adjacent sections were stained for adenosine triphosphatase at pH 10.4 or 4.2. After mounting, magnifying, and photographing, Type I versus Type II fiber types were differentiated by the intensity of, or by the inhibition of, staining of matched fibers at each pH level. Type I fibers stained light at pH 10.4 and dark at pH 4.2, while Type II fibers stained light at pH 4.2 and dark at pH 10.4. MAIN OUTCOME MEASURES: The number of fibers counted for each specimen ranged from 60 to 616. The numbers of Type I and Type II stained fibers appearing in each muscle tissue sample were determined and expressed as a percentage of the total number of fibers identified. A few identified fibers could not be labelled as either Type I or Type II. RESULTS: The overall proportion of Type I fibers, averaged across all specimens, was 59.8%. Male specimens had 67.4% Type I fibers and 31.8% Type II fibers, while female specimens had 54.4% Type I fibers and 44.4% Type II fibers. CONCLUSIONS: Observed fiber type distributions were similar to those reported for other articulatory muscles, but differed slightly from previously reported distributions for normal levator veli palatini. The distributions observed in this study provide a baseline against which to relate fiber type data from the levator veli palatini of cleft palates to the functional status of the velopharyngeal mechanism.     

Postoperative ptosis: etiopathogenesis, clinical analysis, and therapeutic management. Apropos of a series of 43 cases

PURPOSE: Acquired postoperative ptosis (PP) are difficult to situate in the current classification of ptosis. Assessement of the mechanisms, the clinical features and the possible treatments of these PP would suggest a new classification of ptosis. MATERIAL AND METHODS: Among 260 cases of surgically corrected ptosis, 43 cases of PP (16.5%) were detected and analyzed. RESULTS: Forty cases of PP were eligible for this study. Their responsible mechanisms were aponeurotic (57.5%), mixed (aponeurotic and/or myogenic and/or neurogenic) (27.5%) and myogenic (15%). PP was assessed in most cases as being mild (77.5%) and the levator's muscle contraction was most often mildly impaired (77.5%). In these cases, surgical procedure was performed: levator aponeurosis disinsertion repair (85%), Fasanella-Servat procedure (2.5%), frontalis sling (2.5%) and other surgical procedure with synthetic materials (10%). Postoperative complications included 1 case of persistent lid edema and 4 cases of spontaneous suture rupture. Six patients (15%) were secondarily reoperated: 2 for overcorrection (5%) and 4 for undercorrection (10%). The general outcome was good in 90% of cases, insufficient in 5% of cases and unsatisfactory in 5% of cases. CONCLUSION: This study confirms the previously described features of the PP: onset after anterior surgery procedures of usually moderate ptosis, induced by an aponeurotic defect mechanism in most cases. The treatment was exclusively surgical: anterior reinsertion of the levator aponeurosis. For better management, we suggest a new ptosis classification: aponeurotic, myogenic, neurogenic and mixed (aponeurotic and/or myogenic and/or neurogenic) and false or pseudo-ptosis.     

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BACKGROUND/AIM: Patients with thyroid eye disease with upper eyelid retraction often develop overaction of the accessory muscles of eyelid closure, the glabellar muscles corrugator supercilii and procerus. The resultant glabellar furrowing (frown lines) contributes to the typical thyroid facies. The aim of this study was to evaluate the use of botulinum toxin A reversible chemodenervation of the glabellar muscles as adjunctive treatment in the rehabilitation of patients with thyroid eye disease. METHODS: 14 patients (13 females) ages 39-76 years (mean 52) with inactive thyroid eye disease and associated medial eyebrow ptosis and prominent glabellar frown lines were recruited. All patients had a history of upper eyelid retraction. Each patient was treated with a single botulinum toxin injection (Dysport 0.2 ml, 40 units) into each corrugator supercilii and sometimes procerus muscles as an outpatient procedure. The effectiveness and acceptability of the treatment was assessed clinically and from a patient questionnaire. RESULTS: The injections were tolerated by 13/14 (93%) patients. There was resultant flattening of the glabellar region and improvement of medial eyebrow contour in all patients, with onset of paralysis within 1 week. All patients reported a subjective improvement in appearance. Side effects included one patient (7%) with reversible partial ptosis. The beneficial effect lasted 4-6 months, with a gradual return of function. Repeat treatment was indicated where there was persistent upper eyelid retraction and protractor overaction. CONCLUSION: Botulinum toxin A chemodenervation of the glabellar muscles in these patients was effective and acceptable. Chemodenervation should be considered in the rehabilitation of patients with thyroid eye disease where there is upper eyelid retraction and overacting protractors resulting in a thyroid frown. Once the eyelid retraction has been successfully treated by surgery, the need for further glabella muscle chemodenervation is considerably reduced.     

Mechanism of upper lid ptosis in the anophthalmic orbit

The occurrence of upper lid ptosis in 66 patients in the anophthalmic state was 18 percent, despite an adequate prosthesis. The commonly cited causes for this entity do not hold up under examination. A detailed review of the anatomy of the levator mechanism and of the anatomy of an enucleation suggests that the etiology is really based on the production of a mechanical imbalance in the levator apparatus. Suggestions for management and for the timing of the correction (in relation to other surgical procedures) are made.     

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The authors describe a supernumerary muscle in each orbit of an elderly male subject. There appear to be no previous reports of this muscle; most reports of anomalies of extraocular muscles describe hypoplasia or aplasia. Thirty-five formalin-fixed cadavers assigned to medical students for dissection were studied. The orbits were dissected by a superior approach which involved removal of the orbital plate of the frontal bone and the superior orbital margin. A supernumerary extraocular muscle was seen in each orbit of one cadaver, located between the superior oblique and levator palpebrae superioris muscles. It originated on the inferior surface of the lesser wing of sphenoid bone and was inserted into the skin of the medial one-third of the upper eyelid. It was innervated by a branch from the superior division of the oculomotor nerve. The insertion of the muscle into the upper eyelid produced a crease running obliquely upwards and medially, from the junction of the medial one-third and lateral two-thirds of the lid margin, towards the medial part of the superior orbital fold. The authors suggest the name levator palpebrae superioris accessorius for this muscle in view of its topography and action as tested in the cadaver. The significance of the findings is discussed and the literature on the development of the muscles supplied by the oculomotor nerve is reviewed.     

Isolation of the gene and characterization of the enzymatic properties of a major exoglucanase of humicola grisea without a cellulose-binding domain

BACKGROUND: The congenital fibrosis syndrome is a hereditary form of external ophthalmoplegia that is considered to be a primary myopathy. PURPOSE: To document the coexistence of two distinct forms of ocular motor synkinesis in a subgroup of patients with congenital fibrosis syndrome. METHODS: Clinical and intraoperative examination results and extraocular muscle biopsy specimens from four patients with congenital fibrosis syndrome were studied. RESULTS: Three patients displayed a variant of synergistic divergence characterized by simultaneous abduction with intorsion and depression of the synkinetically abducting eye. Three patients had variant of Marcus Gunn jaw winking characterized by elevation of a ptotic eyelid during mouth opening. Three patients had oculocutaneous hypopigmentation. CONCLUSIONS: A subgroup of patients with congenital fibrosis syndrome display two distinct synkinetic ocular movements in conjunction with oculocutaneous hypopigmentation. The patterns of neuronal misdirection implicate a regional innervational disturbance involving cranial nerves III through VI as the underlying cause of diffuse hereditary ophthalmoplegia in these patients.     

Primary meningeal lymphoma in a horse

Primary meningeal lymphoma was diagnosed in an 18-year-old Morgan gelding. The horse was examined because of a 3-day history of progressive ataxia and weakness. The gait abnormalities were worse on the left side, and the pelvic limbs were more affected than the thoracic limbs. Additional findings included signs of depression, miosis of the left pupil, ptosis of the left upper eyelid, and areas of muscle atrophy on the left side of the neck and over the dorsal aspect of the left scapula. Inflammatory changes were evident in the CSF. At necropsy, there was diffuse and irregular thickening of the dura mater along the entire spinal cord. Histologic examination revealed infiltration of the leptomeninges with neoplastic lymphocytes.     

Effect of posture, route of respiration, and negative pressure on palatal muscle activity in humans

Sleep apnea is worse in the supine posture and is associated with retropalatal airway narrowing or occlusion. We have, therefore, examined the effects of posture, negative pressure, and route of respiration on palatal muscle activity in 13 nonsnoring awake male subjects by using electromyography. Electromyographic activity of the levator palatini and palatoglossus was expressed as a percentage of maximum activity. Both the levator palatini (P = 0.002) and palatoglossus (P = 0.002) exhibited phasic inspiratory activity. Overall, posture did not affect the levator palatini (F = 1.58; P = 0.23) or palatoglossus (F = 0.98; P = 0.34) activity, but analysis by route of respiration showed the palatoglossus to be more active when the subjects were nose breathing supine (F = 6.64; P = 0.02). Levator palatini activity was lower when nose breathing was compared with mouth breathing in both the erect and supine postures (F = 6.67; P < 0.02). Nose breathing with the mouth held open caused an increase in palatoglossal activity (P = 0.04). Negative-pressure application (0 to -12.5 cmH2O) caused significant increases in levator palatini (P < 0.001) and palatoglossus (P < 0.001) activity, 100 ms after pressure stimulus, irrespective of route. However, the palatoglossus required significantly greater negative pressures to cause activation when applied via the nose compared with the mouth (P < 0.05). These observations indicate that the levator palatini and palatglossus have respiratory activity and are reflexly activated by negative pressure.     

Increasing the moment arm of the tibialis anterior induces structural and functional adaptation: implications for tendon transfer

Previous studies on the functional effects of tendon transfer have not examined possible muscle adaptation following transfer. The purpose of the present study was to test the hypothesis that muscle adapts to increased moment arm and excursion such that joint torque is maintained near normal levels. The moment arm and excursion of the tibialis anterior (TA) were increased by releasing the TA from its retinacular restraint at the ankle joint in growing (4-week-old) rabbits. Twelve weeks post-release, in vivo TA force during hopping was smaller in released compared with control rabbits, compensating for the increased moment arm, and thus TA torque at the ankle joint was not significantly different between groups. Physiological cross-sectional area was smaller, and the number of sarcomeres in series was larger, in the released TA compared with the control TA. These adaptations may result from chronically decreased in vivo TA force production, and chronically increased TA excursion, respectively. In addition, these adaptations were consistent with the smaller in vivo force for the released TA. Comparisons between control and sham-operated rabbits showed no significant differences for in vivo TA force, torque, or muscle architecture. Thus, muscle appears capable of adapting to increased moment arm and excursion such that joint torque is maintained near normal levels. These findings have important implications for tendon transfer procedures that increase the moment arm and/or excursion of the released muscle.     

Kaposiform haemangioendothelioma associated with Kasabach-Merritt syndrome

PURPOSE: This report evaluates the efficacy of the modified supratrichial brow lift technique. The indications for the procedure, as well as the advantages, effectiveness, and complications are reviewed. PATIENTS AND METHODS: Thirty-six modified supratrichial brow lift procedures were performed bilaterally on 34 female and two male patients. The procedure was used in conjunction with a blepharoplasty in 32 patients and alone in four patients. RESULTS: The procedure improved the cosmetic result in the 32 patients with lateral brow ptosis who had a concomitant upper eyelid blepharoplasty. No complications were encountered. CONCLUSION: The modified supratrichial brow lift can improve the cosmetic result in patients with lateral brow ptosis undergoing an upper eyelid blepharoplasty.     

Treatment of strabismus and nystagmus with botulinum toxin type A. An evaluation of effects and complications

PURPOSE: Injection of botulinum toxin type A into eye muscles leads to a temporary paralysis and the effects have been evaluated in strabismus or nystagmus. METHOD: A total of 112 patients with different types of concomitant and paralytic strabismus and acquired nystagmus were treated with botulinum toxin, according to well-established indications. RESULTS: The lasting effects of the injections on strabismic angle were largest in esotropia, consecutive exotropia and abducens palsy, and amounted to, on an average, 12 prism diopters or 6 degrees. The larger the strabismus the better was the effect. Repeated injections reduced the angle further. In complex nystagmus forms retrobulbar injections could be used. The side effects were mostly due to spread of botulinum toxin to the levator, producing ptosis (8%), or the inferior rectus muscle, causing vertical strabismus (10%). On an average 42% of the patients were later operated for strabismus and nystagmus. CONCLUSION: Injection of botulinum toxin A into eye muscles is a valuable adjunct to surgery in the treatment of strabismus and nystagmus.     

Postcataract ptosis. A randomized, double-masked comparison of peribulbar and retrobulbar anesthesia

PURPOSE: A randomized, double-masked study of 317 patients was conducted to determine if the incidence of postcataract ptosis is greater with retrobulbar or two-injection peribulbar injection anesthesia. METHODS: Surgery consisted of a planned extracapsular extraction with posterior chamber lens implantation, and no superior rectus bridle suture was used. Ptosis was quantitatively documented preoperatively and postoperatively at 1, 2, 5, and 90 days by the surgeon, photographically at 90 days by a masked observer, and subjectively by the patients. Postcataract ptosis was defined as a drop in the lid margin of 2 mm or greater after correcting for any change in the fellow eye. RESULTS: The incidence of ptosis at 90 days in patients given peribulbar anesthesia was 5.8% and in patients given retrobulbar anesthesia 5.5%, and this difference was not statistically significant (P = 0.90). Eighteen percent of patients in both groups reported a change in the appearance of their eyelids. There was a moderate, positive correlation among patients who reported a change in their lid position and objective measurements of ptosis. Preoperative clinical measurements of vertical lid fissure width and levator function, and the appearance of the lid crease or superior sulcus were not predictive for the development of postoperative ptosis at 90 days; the best predictor was the presence of ptosis in the immediate postoperative period. CONCLUSION: The incidence of postcataract ptosis is the same whether two injection peribulbar or retrobulbar anesthesia is used.     

Surgical management of third nerve palsy

AIMS: A surgical technique has been developed in order to obtain ocular alignment in the primary position in patients with third nerve palsy. METHODS: A method for surgically correcting the vertical deviation and the pseudoptosis is described in three patients with longstanding third nerve palsy. By decreasing the ability of the non-involved eye to elevate, a fixation duress was created which eliminated the secondary deviation that characteristically occurs in such patients when the involved eye fixates. As a result of this technique, both eyes in all patients on attempted fixation were under similar duress, therefore requiring equal amounts of stimulation to move into the primary position. When the fixation duress was sufficient, elimination of the hypotropia and ptosis was achieved. Additionally, in order to correct the exotropia, generous recession and resection procedures in the involved eye and recession of the lateral rectus in the noninvolved eye were performed. RESULTS: Between 8 and 10 prism dioptres of esotropia were achieved and maintained in two patients. One patient had 20 prism dioptres of exotropia. Two patients had no residual ptosis and one required an additional anterior levator resection to achieve a satisfactory result. CONCLUSION: Patients with a third nerve palsy and a pseudoptosis may be candidates for this approach.     

Botulinum toxin type A purified neurotoxin complex for the treatment of blepharospasm: a dose-response study measuring eyelid force

The clinical efficacy of botulinum toxin type A was studied in patients with blepharospasm. Clinical symptoms were evaluated using the Jankovic rating scale. To measure dose response, we used a recently developed device to measure eyelid muscle force. The results showed significant improvement (P = 0.0000) in the Jankovic rating scale scores in all dose groups. The number of patients with marked improvement (6-point decrease or more in the total Jankovic rating scale score) increased with higher dose injections. After injections of 0.50, 1.25, or 2.50 U/site, 6 sites/eye, the eyelid muscle force decreased by 33.2 +/- 28.1%, 41.7 +/- 25.1%, or 69.6 +/- 5.0%, respectively. The decrease of eyelid muscle force showed a significant dose response (P = 0.0254). The mean duration of effect was 12.9 weeks in patients after dose injections of 1.25 U/site, which was significantly longer (P = 0.0205) than the 9.6 weeks in patients after dose injections of 0.50 U/site. No severe adverse effects were observed. We concluded that injections of botulinum toxin type A at an initial dose of 1.25 U/site are a safe and effective treatment for blepharospasm.     

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The authors report on a 62-year-old woman who suffered from partial nuclear oculomotor nerve palsy and the medial longitudinal fasciculus (MLF) syndrome caused by midbrain infarction. The lesion was confirmed to be in the mesencephalic tegmentum by axial sections acquired by magnetic resonance imaging (MRI). The lesion was located in the caudal region of the mesencephalic tegmentum by the sagittal MRI sections, and showed low signal intensity in T1-weighted images and high signal intensity in T2-weighted images. The patient exhibited bilateral ptosis due to the disturbance of caudal central nucleus and the supra-oculomotor area on both sides innervating the levator muscles of the upper eyelid. She also showed bilateral limitation of ocular adduction and supraduction; mild infraduction of the left eyeball; left monocular nystagmus; and disturbance of convergence, indicating partial involvement of the lateral somatic cell column innervating the muscles of the eyeball, the rostral interstitial nucleus of the medial longitudinal fasciculus (riMLF) and the MLF. Furthermore, transient visual hallucinations similar to hallucinose pédonculaire were confirmed. We are not aware of any reports describing simultaneous occurrence of bilateral ptosis, MLF syndrome, and transient visual hallucinations similar to hallucinose pédonculaire in the same patient.     

Extraocular fast myosin heavy chain expression in the levator palpebrae and retractor bulbi muscles

PURPOSE: To determine whether the levator palpebrae superioris (LPS) and the retractor bulbi (RB) muscles, which share contractile characteristics with extraocular muscles (EOMs), express fast EOM-specific myosin heavy chain (MyHC) in the rabbit and other mammalian species. METHODS: Cryostat sections of rabbit eye and limb muscles were stained by indirect peroxidase immunohistochemical procedures using monoclonal antibodies (MAbs), including one (4A6) against EOM-specific fast MyHC. Myosin heavy chain isoforms from these muscles were separated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE), and the 4A6-reactive component was identified by immunoblotting. RESULTS: MAb 4A6 stained muscle fibers in rabbit LPS and RB. SDS-PAGE resolved a rabbit EOM-specific MyHC isoform (band 1) from two other components (bands 2 and 3) that comigrated with limb fast MyHCs. MAb 4A6 reacted only with band 1. Rabbit LPS and RB also displayed corresponding MyHC components with the same mobilities and immunoreactivities as bands 1 to 3 in the EOM. MAb 4A6 also stained muscle fibers in monkey and cat LPS, but it failed to stain muscle fibers in cat RB and rat LPS and RB. CONCLUSIONS: The expression of EOM-specific fast MyHC in EOM, LPS, and RB reflect their common developmental origin and similar contractile characteristics. These properties set them apart from other skeletal muscle groups. Eye muscles may constitute a distinct muscle group or allotype characterized by unique properties, including their propensity or resistance to disease.