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Background Botulinum toxin A (BoNT-A) has grown tremendously in aesthetic dermatology since 2002 when the United States Food and Drug Administration (FDA) first approved its use for treating moderate-to-severe glabellar lines. Blepharoptosis, due to local spread of toxin, is a reported side effect of BoNT-A which, although rare, more frequently occurs among inexperienced practitioners. Objectives The purpose of this review is to highlight the causes and management of eyelid ptosis secondary to BoNT-A administration including new anatomic pathways for BoNT-A spread from the brow area to the levator palpebrae superioris muscle. Methods A literature search was conducted using electronic databases (PubMed, Science Direct, MEDLINE, Embase, CINAHL, EBSCO) regarding eyelid anatomy and the underlying pathogenesis, presentation, prevention, and treatment of eyelid ptosis secondary to BoNT-A. Anatomic dissection has been performed to assess the role of neurovascular pedicles and supraorbital foramen anatomic variations. Results Blepharoptosis occurs due to weakness of the levator palpebrae superioris muscle. Mean onset is 3-14 days after injection and eventually self-resolves after the paralytic effect of BoNT-A wanes. Administration of medications, such as oxymetazoline hydrochloride or apraclonidine hydrochloride eye drops, anticholinesterase agents, or transdermal BoNT-A injections to the pre-tarsal orbicularis, can at least partially reverse eyelid ptosis. Anatomic study shows that a supraorbital foramen may be present in some patients and constitutes a shortcut from the brow area directly into the orbital roof, following the supraorbital neurovascular pedicle. Conclusion Providers should understand the anatomy and be aware of the causes and treatment for blepharoptosis when injecting BoNT-A for the reduction of facial wrinkles. Thorough anatomic knowledge of the supraorbital area and orbital roof is paramount to preventing incorrect injection into "danger zones," which increase the risk of eyelid ptosis.

Background: This study aims to revisit the anatomy of orbital segment of the third cranial nerve (CN III). The study also involved morphometric measurements of CN III muscular branches. Detailed description of observed anatomical variations and their incidence was also included. The study supplements earlier findings with detailed observations of the neuromuscular relations. Materials and methods: The study was conducted on 52 orbits taken from 26 cadaveric heads (10 males and 16 females; Central European population). Results: Anatomical variations of the orbital segment of the CN III observed on the examined material involved both the superior and inferior branch of this nerve. The muscular branch innervating the levator palpebrae superioris muscle occasionally pierces the superior rectus muscle. The nerve to the inferior oblique muscle may pierce and innervate the inferior rectus muscle. In rare instances, duplication of the parasympathetic root of the ciliary ganglion may also occur. Among the muscular branches, the smallest diameter reached the branch to the levator palpebrae superioris muscle. Among the three muscular branches derived from the inferior branch of the CN III, the nerve to the inferior oblique was the longest one. Its length varied from 28.9 mm to 37.4 mm. The shortest was the muscular branch to the inferior rectus muscle. Its length varied from 0 mm (when muscular sub-branches arose directly from the nerve to the inferior oblique muscle) to 7.58 mm. Conclusions: This study presented the characteristic of orbital segment of the CN III, including anatomical variations and morphometric measurements relevant to intraorbital procedures.

Myotonic dystrophy is a systemic disorder associated with progressive muscle weakness of the extremities and multi-organ dysfunction. This condition commonly affects the levator palpebrae superioris muscle, which leads to ptosis and eventually affects patients' activities of daily living. The effects of ptosis on activities of daily living are usually overlooked; therefore, the importance of treatment is underestimated, and surgical procedures are considered infeasible in patients with pre-existent levator palpebrae superioris muscle weakness. This case report describes the case of a middle-aged man with myotonic dystrophy type 1, who presented with ptosis, which significantly restricted his participation in rehabilitation and activities of daily living secondary to a limited visual field. He was evaluated by an ophthalmologist; however, surgery was contraindicated in view of the high risk of complications, such as exposure keratitis and corneal ulcer. Double eyelid tapes were used as a non-surgical intervention, which significantly increased the palpebral fissure height and improved the visual field, with a higher modified functional index score. Double eyelid tapes may serve as an effective, safe, and reliable therapeutic option for severe ptosis in patients with myotonic dystrophy.

Background To study the anatomical characteristics of retro-orbicularis oculi fat (ROOF) in the upper eyelid and to investigate its relevance in upper eyelid surgery. Methods Thirty-eight Chinese hemifacial cadaver specimens were used. Several sagittal plane section planes were recorded from the medial canthus to the lateral canthus of the eyelid after P45 sheet plastination. ROOF and the associated orbital septum connective tissues in the 38 hemifaces were studied. According to the anatomic results, the lowest point of the junction of the orbital septum and the ROOF (SRJ) was raised for surgical dissection. We improved the intraoperative management of patients who underwent upper eyelid surgery in the plastic surgery department of the First Affiliated Hospital of Dalian Medical University in 2019. Patients were evaluated by observation and self-assessment. Results ROOF is fascia adipose tissue. In the upper portion of upper eyelid, ROOF fibers were observed to be extremely dense and continuous with the fascia on the surfaces of orbicularis oculi muscle, the periosteum of the orbital margin, and the orbital septum. In the middle portion, positional relationships were identified between the lowest point of the SRJ and the lowest point of the junction of the orbital septum and the levator palpebrae superioris (SAJ). Lifting the SRJ significantly increased the upper eyelid reflex distance in all 57 patients. Conclusions ROOF is an important factor in upper eyelid surgery. Lifting the SRJ effectively improves the retraction force of the levator palpebrae superioris muscle (LPS).

In this experimental anatomic study, the authors examined the number and distribution of muscle spindles in the levator palpebrae superioris (LPS) muscle of human adults. This study included 11 orbits from 11 cadavers (mean age at death, 81.9 years). The LPS muscles were harvested and equally divided into 5 sections using transverse incisions. Muscle spindles were counted in each section. Consequently, muscle spindles were identified in 4 (36.4%) of the 11 orbits studied. One to 4 muscle spindles were identified in each of these 4 orbits. All muscle spindles were found in the most proximal section (the muscle origin), and no muscle spindles were identified in the other sections. The results indicate that the LPS muscle is associated with a smaller number of muscle spindles as compared with the rest of the extraocular muscles. Since higher muscle spindle numbers are associated with finer motor movements, eyelid opening does not seem to require much precision, compared to ocular movement.

To describe a novel observation of ipsilateral eyelid myokymia in the context of Marcus Gunn jaw-winking synkinesis (MGJWS).A retrospective case series of 5 patients observed to have myokymia in the context of MGJWS in 2 tertiary hospitals in Riyadh, Saudi Arabia was conducted. Demographic profile including age and gender, and clinical features were analyzed.Five patients (3 males and 2 females) with MGJWS were noted to demonstrate the phenomenon of ipsilateral eyelid myokymia. All but 1 had right-sided MGJWS. The myokymia was seen as upper eyelid twitching in a vertical fashion along the levator palpebrae superioris muscle field of action. All subjects also had ipsilateral Monocular elevation deficiency.Ipsilateral upper eyelid myokymia is a potential feature of MGJWS. Monocular elevation seems to be a constant feature among MGJWS patients with levator muscle myokymia.Marcus Gunn jaw-winking synkinesis (MGJWS) is not well understood. Ipsilateral eyelid myokymia is a potential feature of MGJWS. This finding suggests that peripheral dysinnervation is likely to be a part of MGJWS.Supplemental Digital Content is available in the text.Marcus Gunn jaw-winking synkinesis (MGJWS) is not well understood. Ipsilateral eyelid myokymia is a potential feature of MGJWS. This finding suggests that peripheral dysinnervation is likely to be a part of MGJWS. Supplemental Digital Content is available in the text.

Background:. The purpose of this article is to clarify the character of Müller’s muscle in Chinese specimens. Methods:. Ten upper eyelids of 10 formalin-fixed Chinese cadavers (9 elderly people, from 68 to 86 years of age; 1 male child, 10 years old) were examined. Full-thickness sagittal sections of the central part of the upper eyelids were microscopically examined using hematoxylin-eosin, Masson trichrome, and anti–smooth muscle actin antibodies staining. Result:. In 9 elderly specimens, Müller’s muscle inserted onto tarsus via fibers, and the smooth muscle components decreased gradually and even faded away from the originated inferior branch of levator palpebrae superioris muscle to the upper margin of tarsus, although, in 1 child specimen, Müller’s muscle inserted directly onto tarsus rather than connective fibrous structure, and smooth muscle components did not decrease obviously. Both in elderly and young specimens, the aponeurotic structure that originated from Müller’s muscle extended to the tarsal plate. Conclusion:. This study suggests that Müller’s muscle inserts onto the tarsus via fibrous tissue or smooth muscle, and also indicates that the smooth components of Müller’s muscle may decrease gradually in elderly people.

Introduction: The ptosis is a fall of the upper eyelid in relation to a deficit of the levator device of this one. In practice, it poses two major problems, the first one is the eminent risk of amblyopia during severe congenital ptosis, and the second is of an aesthetic nature, representing the main reason for consultation. The aim of this work is to evaluate the interest of the levator palpebrae superioris muscle plication in the ptosis surgery. Materials and Methods: We collected 12 patients who received a correction of their ptosis by plication of the levator palpebrae superioris muscle over a period of 3 years from January 2012 to December 2014. Result: The mean age at treatment was 22 years; the ptosis was congenital in 8 cases, and acquired in 4. The ptosis was major in 67% and moderate in 33% of the cases. Muscle plication was the basic surgical technique in all patients in our series. The function and aesthetic results were satisfying in 6 cases (50%), good in 4 cases (34%), acceptable in 1 case and bad in 1 case (8%). Discussion: The comparative study has shown that the plication of the levator palpebrae superioris muscle is a possible alternative for the correction of ptosis whatever the type of ptosis with results comparable to the reference technique compared to the degree of correction, whereas the operative follow-up is simpler and more minor complications. Conclusion: The surgical treatment of ptosis should be done after a systematic clinical examination and after very precise indications. However, the plication of the levator muscle of the upper eyelid has shown its functional and aesthetic efficiency in congenital ptosis and in the ptosis of the adult.

We report a rare case of unilateral localized amyloidosis of levator palpebrae superioris (LPS) muscle causing blepharoptosis. A 71-year-old male presented with a history of gradually progressing left upper eyelid ptosis. LPS resection was planned and the resected unusually thickened muscle was sent for histopathological examination which revealed amyloidosis. Investigations excluded systemic involvement. Amyloidosis should be considered in the differential diagnosis of aponeurotic ptosis.

PURPOSE: To examine a part of the levator aponeurosis/levator palpebrae superioris (LPS) muscle that did not have fatty deposits in patients with aponeurotic blepharoptosis. We also analysed the relation between this length and surgical outcome after transcutaneous aponeurotic repair. METHODS: We measured the vertical length from the distal end of the anterior layer of the levator aponeurosis to the most distal point of fatty deposits in the levator aponeurosis/LPS muscle (non-fatty-deposit length) in 94 eyelids. Surgical success was defined as a postoperative margin reflex distance-1 (MRD-1) of 2.0–5.0 mm at 3 months postoperatively. The eyelids were classified into two groups: a surgical success group (group A, 76 eyelids) and an undercorrected group (group B, 18 eyelids). Group A was subdivided according to the evidence of a fatty deposit (group A1, fat present, 70 eyelids; group A2, fat absent, 6 eyelids). RESULTS: The non-fatty-deposit measurement was significantly longer in group A1 than in group B (p = 0.035). The levator aponeurosis was less advanced in groups A1 and A2 than in group B (both, p

Purpose To review and summarize the clinical findings in thyroid eye disease (TED) related to the unique anatomical structures of the eyelids and orbit. Methods A PubMed search was performed searching for anatomical relationships between eyelid and orbital anatomy and the clinical findings of TED. Results The major clinical findings associated with TED are varied. They typically involve both the eyelid and the orbit. In the eyelid, usual findings include upper eyelid retraction, contour abnormalities, eyelid edema, prolapsed orbital fat, conjunctival injection and chemosis, caruncular edema, and meibomian gland dysfunction. The exact causes of these changes remain a matter of controversy, but numerous hypotheses have been proposed, most with limited experimental support. In the orbit, inflammation and congestion characterize the acute active phase, with tissue expansion and fibrosis persisting into the chronic inactive phase. All of these findings result, at least in part, from the unique anatomy of the eyelids and orbit and their interaction with the immunologic processes underlying TED. Here we review these major characteristics of TED, with special reference to their anatomic relationships. Conclusions The major findings characterizing TED are related to unique anatomic features in the eyelid, including Muller muscle, the levator palpebrae superioris muscle, and suspensory ligaments of the conjunctiva. In the orbit, Graves-related remolding results from the special physiologic features of the extraocular muscles, the structure of the orbital walls and their relations to adjacent paranasal sinuses, and the reaction of orbital fat to immunologic challenges.

Purpose: Upper eyelid ptosis has different etiologies in children and adults. In children, the common causes include orbital cellulitis, congenital ptosis, Cranial Nerve (CN) III palsy, and Horner's syndrome. The purpose of this report is to discuss an unusual presentation of ptosis. Observations: We describe a case of a 9-year-old boy with left-sided ptosis with no apparent clinical signs of orbital or preseptal infection. Magnetic resonance imaging (MRI) revealed pansinusitis and contralateral otitis media with direct extension into the superior aspect of the left orbit affecting the levator palpebrae superioris muscle. Conclusions and importance: This finding on imaging disclosed the etiology of an otherwise unexplained case of upper lid ptosis. Keywords: Ptosis, Pansinusitis, Orbital cellulitis, Otitis media

Background Some fordless-eyelid patients with moderate upper lid ptosis characterize in a higher eyebrow position which leads to an increased midfacial ratio. Apart from performing blepharoplasty to create dynamic folds, additional procedures such as folding aponeurosis of levator palpebrae superioris muscle were effective to revise the enlarged ratio of midface through lowering eyebrow, which gains good aesthetic results. However, the specific changes in the proportion of facial aesthetics and the importance of these change were serious lack in the literature as far as the authors know. Purpose To measure the ratio of the length between upper edge of eyebrow and edge of lower eyelid (L1)/the length between edge of lower eyelid and nasal base (L2) in the fordless-eyelid and upper lid ptosis patients who received levator aponeurosis folding surgery, and to analyze the change in the proportion of midfacial aesthetics. Method From December 2015 to October 2016, the pre- and postoperative photographs from 21 cases of patients with foldless eyelid and upper lid ptosis who underwent the levator aponeurosis folding procedures in the authors' department were collected as study group. Additional full-face pictures of 20 Chinese female movie stars were prepared as control group. The ratios of L1/ L2 (J) were measured via Adobe Photoshop CS6. The statistical significance was analyzed and the change of midfacial proportion was evaluated. Result In the study group, the mean value of preoperative L1/L2 (J1) is 0.746, and (J2) 0.657 postoperatively. In the control group, the mean value of L1/L2 (J3) is 0.667. Statistical differences showed between the pre- and postoperative samples and between preoperative samples and control group. There was no statistical difference between postoperative samples and control group samples. The ratios between L1 and L2 in postoperative samples are close to those in the control group, which are closer to the golden radio. Conclusion Levator aponeurosis folding can effectively lower eyebrow in patients with upper lid ptosis, shortening the length between eyebrow and lower eyelid, and therefore harvesting a more appropriate and harmonious ratio of L1/ L2 according to the golden section theory. The changes in the proportion of midfacial aesthetics after operation could be used as a key point in the preoperative communication and postoperative effect evaluation, besides the size of palpebral fissure and corneal exposure rate.

The classical levator resection (LR) technique for correcting ptosis involves separating the levator palpebrae superioris muscle (LPS) completely, which will inevitably collapse the muscle. The modified surgical method involving retention of the LPS suspensory system can allow for more contractility of the levator muscle and thus maximize protection of the eyelid structure. Ninety patients (132 eyelids) with different degrees of ptosis were enrolled. The same levator resection surgery whereby the suspensory system of the LPS is retained was performed in each patient. Postoperative outcome measures included the following: position of the upper eyelid margin, eyelid contour and plumpness, degree of scleral exposure, and exposure keratitis. Postoperative follow-up time points were 1 week, 1 month, and 6 months. The positions of the eyelid upper margins were normal in all cases, and lagophthalmos only existed in severe cases in the early stage after surgery. Six months after surgery, 32% of the eyes had residual ptosis to varying degrees among severe cases, and the mild and moderate cases exhibited good surgical outcomes. The eyelids had appropriate closing functionality, and exposure keratitis was not observed in any case. Eyelid contour and plumpness was satisfactory in all patients. Retaining the suspensory system of the LPS for LR with a modified surgery can protect the normal function and morphology of the eyelids. The surgery had a high success rate, especially for cases of mild and moderate ptosis. 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.

Ischaemic oculomotor nerve (CN III) palsies frequently present with abrupt onset ptosis, ophthalmoplegia, diplopia, ipsilateral pain, and little to no anisocoria. An isolated microvascular ischaemic insult to the superior division of CN III is uncommon, and usually affects both the superior rectus and levator muscles. We present a rare case of an ischaemic CN III palsy isolated to the levator palpebrae superioris muscle only. Although rare, microvascular ischaemic CN III palsies should be on the differential of isolated ptosis. Other causes of isolated ptosis, such as myasthenia gravis or an orbital lesion, should be excluded.

A comparison of the superior and inferior rectus muscles was performed to determine whether they have similar structures and innervation attributable to their participation in the same type of, although antagonistic, eye movements. The study was conducted on 70 cadaveric hemiheads, and the anatomical variations in the superior and inferior rectus muscles were assessed. Sihler’s whole mount nerve staining technique was used on 20 isolated superior and 20 isolated inferior rectus muscle specimens to visualize the intramuscular distribution of the oculomotor nerve subbranches. In two cases (~2.8%), variant muscular slips were found that connected the superior and inferior rectus muscles. In 80% of cases, muscular branches arising directly from the inferior branch of the oculomotor nerve innervated the inferior rectus muscle, while in 20% of cases, the nerve to the inferior oblique muscle pierced the inferior rectus muscle and provided its innervation. In 15 of 70 specimens (21.4%), a branch to the levator palpebrae superioris muscle pierced the superior rectus muscle. The distance between the specific rectus muscle’s insertion and the anterior-most terminations of the nerves’ subbranches with reference to the muscle’s total length ranged from 26.9% to 47.2% for the inferior rectus and from 34.8% to 46.6% for the superior rectus, respectively. The superior rectus muscle is slightly longer and its insertion is farther from the limbus of the cornea than is the inferior rectus muscle. Both muscles share a common general pattern of intramuscular nerve subbranches’ arborization, with characteristic Y-shaped ramifications that form the terminal nerve plexus located near half of the muscles’ length. Unexpected anatomical variations of the extraocular muscles may be relevant during orbital imaging or surgical procedures.

PURPOSE To assess the effect of releasing the central attachment between the Whitnall's ligament (WL) and the levator palpebrae superioris muscle on the postoperative levator function (LF), eyelid lag, and degree of lagophthalmos. METHODS This retrospective case-control study included patients with moderate and severe simple congenital ptosis who underwent skin approach levator aponeurosis resection (LR) as a primary procedure with a minimum of 6-month follow up. Patients were divided into 2 groups; the first group underwent LR without WL release (control group) while the second group underwent LR with WL release. Preoperative demographics and clinical data were reviewed. Postoperative LF, eyelid lag, and degree of lagophthalmos as well as surgical outcomes were compared and analyzed in both groups. RESULTS A total of 81 patients (88 eyelids) were included in this study. There were 50 males (61.7%). The mean age was ±SD 12.0 ± 9.5 years. The first group included 43 eyelids while the second had 45 eyelids. There was no statistical difference in demographics and preoperative data between both groups. The postoperative LF was higher in the second group (10.7 ± 2.1 mm) with less consecutive eyelid lag compared with the control group (7.8 ± 1.9 mm) (p < 0.001). The control group had acquired more postoperative lagophthalmos compared with the second group (p < 0.001). Complete surgical success was achieved in 82.2% in the second group compared with 60.5% in the control group (p = 0.024). CONCLUSIONS Releasing the central attachment between WL and levator palpebrae superioris muscle has achieved an improvement in LF with minimal postoperative eyelid lag, lagophthalmos, and corneal complications.Releasing the central attachment between levator palpebrae superioris muscle and Whitnall's ligament during levator aponeurosis resection allows better levator excursion and minimizes postoperative lagophthalmos, eyelid lag, and corneal complications.

Background The levator palpebrae superioris muscle (LPS) acts as the upper eyelid’s major elevator and retractor and is innervated by the oculomotor nerve. The muscle’s paralysis is manifested by ptosis. Material and methods 70 orbits were dissected. After removing the orbital roof, the LPS’ shape and anatomical variations (i.e., the presence of accessory muscular bands or atypical formation of the muscle) were assessed. To visualize the distribution of the oculomotor nerve’s intramuscular sub-branches, the isolated levator palpebrae superioris muscles were stained using Sihler’s staining technique. Results Several LPS anatomical variations were observed in the specimens examined, in seven of which (7/70; 10%) additional delicate muscular slips arose from the LPS’ lateral border and reached the lacrimal gland. Histological examination confirmed the presence of striated skeletal muscle fibers in all those cases. In three other specimens (3/70; 4.28%), supernumerary muscular bands (“tensor trochleae”) were found that linked the levator with the superior oblique muscle’s trochlea. In the next case, the LPS’ origin was double and the muscle was bipartite on its proximal half. In most cases (55/70; 78.6%), muscular branches formed a single bundle that wrapped around the superior rectus muscle’s medial border to reach the levator’s inferior surface. Intramuscular sub-branches were distributed largely within the proximal two-thirds of the LPS and formed an irregular, tree-like pattern. However, thin sub-branches and small retrograde sub-branches extended as far as the muscle’s insertion. Conclusions Plastic surgeons and ophthalmologists should be aware of the levator palpebrae superioris muscle’s anatomic variations both in planning and conducting surgeries on the upper eyelid.

Background Congenital ptosis is a drooping of one or both eyelids at birth, often due to poor development of the levator palpebrae superioris muscle. This can result in amblyopia, astigmatism, and ocular torticollis and therefore may necessitate surgical intervention in early childhood if visual development is compromised. Patients may have varied levels of levator function. Those with moderate to good function may elect to first attempt ptosis repair with external levator advancement or mullerectomy/Fasanella-Servat procedures. For those with poor function, those procedures are less likely to be effective, so they may undergo frontalis sling surgery, in which the tarsal plate is coupled to the frontalis muscle, so that movement of the brow and forehead result in movement of the eyelid. The optimal material to use in this surgery is unknown. Objectives To evaluate the comparative effectiveness and safety of various materials used in frontalis sling surgery for congenital ptosis. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (June 2018), Ovid MEDLINE, Ovid MEDLINE E-pub Ahead of Print, Ovid Medline In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily (January 1946 to 20 June 2018), Embase (January 1947 to 20 June 2018), PubMed (1948 to 20 June 2018), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to 20 June 2018), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 20 June 2018. Selection criteria We included randomized trials that compared one material to another for the treatment of congenital ptosis. Data collection and analysis Two review authors independently completed eligibility screening, data abstraction, 'Risk of bias' assessment, and grading of the evidence. Main results We identified three randomized trials that had compared four different materials, two materials in each trial. The studies included a total of 160 participants. The surgical procedures compared were polytetrafluoroethylene (Gore-Tex), Ethibond suture, Mersilene mesh, and autogenous fascia lata.We judged all studies to be at unclear risk of bias due to incomplete reporting of methods and other methodological deficiencies.Because the three included studies compared different types of implants, we were unable to combine data in a meta-analysis. The limited data preclude any conclusion regarding the optimal implant for frontalis sling surgery.In terms of the primary outcome of functional success, this was defined as widening of the opening between eyelids, assessed either by grade or by millimeter measurement. Bajaj 2004 showed that 93% of the Gore-Tex group and 83% of the Ethibond group had a good or satisfactory outcome (as defined by investigators). Elsamkary 2016 reported that 78.1% of the autogenous fascia group and 61.8% of the Gore-Tex group had a very good or good outcome. Salour 2008 did not include this type of grading system; they showed that the lid fissure increased 4.0 mm ± 1.46 mm in the Mersilene group and 3.13 mm ± 1.72 mm in the fascia lata group.In terms of adverse events, Bajaj 2004, which included 15 patients per group, showed no recurrence in the Gore-Tex group and 1 in the Ethibond group; no need for removal in the Gore-Tex group and 1 in the Ethibond group; and no infections in the Gore-Tex group and 1 in the Ethibond group. Elsamkary 2016, which included 55 patients per group, had 3 recurrences in the fascia group and 6 in the Gore-Tex group; no need for removal in either group; and 1 infection in the fascia group and 2 in the Gore-Tex group. Salour 2008, which included 10 patients per group, had no recurrence, removals, or infections in either the Mersilene or the fascia group. Authors' conclusions The three trials included in this review evaluated four materials for frontalis sling surgery. Assessment of these three studies does not allow us to identify the optimal material. Future randomized trials should be rigorously designed so as to identify the best treatment for this condition.

Goal The location and anatomical relationships of the superior oblique muscle make surgical intervention difficult. The aim of the present paper was therefore to supplement existing anatomical descriptions of this muscle. Its anatomical variability is particularly emphasized, including variations in muscle and tendon size and details of the innervation pattern. Materials and Methods The study was conducted on 78 orbits from 39 adult human cadavers of both sexes (18 males and 21 females). The roof and upper part of the medial and lateral walls of the orbit were carefully removed, which allowed the superior oblique muscle and trochlear nerve to be exposed along their entire course. Sihler's stain was applied to visualize the intramuscular distribution of the trochlear nerve. Results The length of the muscle between the origin and trochlea ranged from 37.8 to 56.5 mm, the length of the tendinous expansion ranged from 16.3 to 22.8 mm, and the width of the scleral insertion of the muscle's tendon ranged from 5.4 to 9.6 mm. In two cadavers, accessory muscular slips connecting the levator palpebrae superioris muscle to the trochlea of the superior oblique muscle were present unilaterally. The distance from the level of the trochlea attachment to the anteriormost endings of the intramuscular branches varied from 17.2 to 21.5 mm. Conclusions The intramuscular nervous branches of the trochlear nerve form a tree-like pattern. Unexpected anatomical variations such as accessory muscular bands could be relevant during orbital imaging or surgeries.

We report the case of a patient with bilateral blephaloptosis associated with a recurrence of diffuse large B-cell lymphoma (DLBCL) in the midbrain. A 70-year-old man experienced acute onset bilateral blephaloptosis; the other ocular movements, except for medial rectus muscle in the right eye, were not impaired. Pupils were isocoric and light reflexes were prompt. Other cranial nerves were intact. Gadolinium-enhanced MRI revealed abnormal enhancement in the midbrain and peri-ventricular regions. FDG-PET revealed an abnormal positive signal in the midbrain, similar to the distribution seen in the MRI scan. Cytology of the cerebrospinal fluid showed large atypical lymphocytes. These findings suggest that the recurrence of DLBCL in the midbrain caused bilateral blephaloptosis. The oculomotor fascicle is localized in the paramedian ventral midbrain. The fascicular fibers are divided topographically into four regions; the lateral, medial, rostral and caudal regions. In three-dimensional arrangement of the oculomotor fascicle, the fibers to the levator palpebrae superioris muscle and medial rectus muscles are located adjacently in caudal regions. Thus, we speculate that recurrence of DLBCL in the midbrain involving the right oculomotor fascicle caused blephaloptosis in the right eye, and then, infiltration of DLBCL to the left oculomotor fascicle subsequently caused blephaloptosis in the left eye. This is a valuable case to be documented in which neurological site of lesions consistent with those are found in radiological study.

Administration of local anesthetics is daily routine for most dental practitioners. Normally, the effect is achieved, and no adverse effects are seen. In this article, the authors describe the complications of immediate, intense and shooting pain, numbness, and marked pallor of the cheek, which occurred during infiltration of a local anesthetic in buccal vestibule infiltration. The patients moved suddenly because of pain and marked pallor of the cheek near the root of the nose and lower eyelid pallor was observed. The pain was very short and the injection was performed again after a few minutes. Two patients also reported an alteration of vision or paralysis of the extra-ocular muscles and drooping eyelid due to paralysis of the levator palpebrae superioris muscle and signs of numbness in the infraorbital area on the same side as the anesthesia. While 3 patients were also apprehensive and started to scare with heart palpitations, as they did not understand what was happening. Probably the anesthetic solutions were injected into an intravascular artery and passed from the extraosseous branch of posterior superior alveolar artery through to the infraorbital artery, which could produce the clinical signs observed in the present study. At the same time, the inoculation of anesthetic in the artery could be grounds for legal disputes for the dentist. In fact, in the absence of vascular disease, anomalies documented by the dentist, they would, however, respond to professional liability and be liable for damages caused to the patient. In conclusion, despite the fact that this condition requires no treatment, it could lead to the recognition of clinical signs in patient with injection of local anesthesia into the artery. At the same time, the inoculation of anesthetic in the artery could be grounds for legal disputes for the dentist.

To assess the relationships between eyelid position and levator palpebrae superioris (LPS)-superior rectus (SR) complex and inferior rectus (IR) muscle volume in patients with Graves’ orbitopathy (GO) with unilateral upper eyelid retraction. This was a cross-sectional observational study of 48 patients with GO with unilateral upper eyelid retraction. To measure muscle volume, computerized tomography scans were performed, and 3D images were analyzed. Digital photographs were taken, and vertical eyelid height was measured using computed eyelid analysis software. The measured muscle volumes and eyelid heights were assessed, and correlation analysis was performed. To verify the parameters that are predictive for the presence of upper eyelid retraction, receiver operating characteristic curves were analyzed, and logistic regression was performed. The volume of the LPS/SR muscle complex in the eyes with upper eyelid retraction was increased in 41 eyes (85.4%). The mean volume of the LPS/SR complex was 0.92 ± 0.40 cm3 in the eyes with upper eyelid retraction and 0.72 ± 0.27 cm3 in the contralateral eyes (p

Direct muscle neurotization has been proved to be a feasible technique for facial reanimation microsurgical procedures. Direct muscle neurotization is performed by implanting the interposition nerve graft directly into the substance of the muscle. The authors present the case of a 36-year-old male patient with upper eyelid dysfunction secondary to facial trauma. The levator palpebrae superioris muscle was macroscopically unaffected; however, neurophysiological test proved a selective denervation of the CN III motor branch to the levator palpebrae superioris muscle. Direct muscle neurotization was performed by means of 2 separate nerve procedures. The authors have made follow-up for 3 months after surgery. The authors have noted development of upper eyelid movement meaning adequate function of the neurotized muscle. The authors believe that this procedure could be integrated into the surgical options to treat selective nerve injuries should the right patient is encountered.

The study was designed to compare the outcome of full-thickness blepharotomy and transconjunctival eyelid lengthening in the correction of upper eyelid retraction (UER) in patients with Graves’ orbitopathy (GO). This is a prospective randomized interventional study. Following ophthalmic examination, determination of the ocular surface disease index (OSDI) and photography, 27 patients with UER were randomly assigned to either graded full-thickness blepharotomy (G1) or transconjunctival Muller muscle recession and graded disinsertion of the levator palpebrae superioris muscle (G2). Six months later, patients were reevaluated. Digital images were analyzed with the assistance of customized software. A standardized “normal range” of upper eyelid height and contour was calculated based on healthy controls. The outcome of the two groups was compared. Forty-seven eyelids of 27 patients (19 female) with UER were included. Twenty-seven eyelids (15 patients) were allocated to G1 and 20 eyelids (12 patients) to G2. On average, surgery lasted 37.46 ± 5.73 min in G1 and 32.70 ± 8.39 min in G2. Based on the margin reflex distance, 93% of the eyelids in G1 and 85% in G2 were within the normal range after surgery. The corresponding figures for lid contour were 63 and 55%. Both groups displayed significant improvement in OSDI scores. No significant difference was observed in the overall comparison. The two surgical techniques were equally effective in the treatment of UER from GO. Postoperative contour outcomes were considerably worse in patients with severe UER than in patients with mild or moderate UER, regardless of group. 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 . Study registered on ClinicalTrial.gov number: NCT01999790

Isolated unilateral congenital ptosis is encountered relatively infrequently in clinical practice. It typically consists of a unilateral droopy eyelid, weak levator palpebrae superioris muscle function, lid lag, and an absent upper lid crease with no other abnormalities on examination. We present a four-and-a-half year old girl with isolated and mild unilateral congenital ptosis who unexpectedly demonstrated a static upper eyelid on downgaze in conjunction with a well-formed upper lid skin crease. We attribute this uncommon sign in congenital ptosis to stiffness and presumed fibrosis of the levator muscle. Examining the function of the eyelids in all directions of gaze is important in patients with abnormalities of lid position, since additional useful information can be gleaned about the status of the levator muscle including, aberrant regeneration or fibrosis.

Purpose: To analyze the cosmetic and functional results of a large series of patients with unilateral congenital ptosis without spontaneous compensatory ipsilateral frontalis hyperaction who underwent supramaximal levator resection (SMLPSr). Methods: A multicenter retrospective review of 35 children (14 girls and 21 boys) of mean age 5.5 ± 3.6 SD years with unilateral congenital ptosis who underwent surgery in 3 different countries: Italy, n = 8; Argentina, n = 11; and Brazil, n = 16. Preoperative evaluation included measurements of upper eyelid margin reflex distance (MRD 1 ) and levator palpebrae superioris muscle excursion, assessment of frontalis hyperaction, and ocular motility examination. At least 6 months postoperatively, photographs were used to measure the upper eyelid contour of OU. The spontaneous blinking amplitude and downward eyelid saccades of OU were quantified in a subset of 14 patients. Quantitative comparison among the 3 centers was performed with nonparametric 1-way analysis of variance (Kruskal–Wallis). Paired t tests were used to compare the pre- and postoperative measurements, and p value < 0.05 was statistically significant. Results: The mean preoperative MRD 1 of the operated eyes increased from 0.5 ± 1.1 SD mm to 3.4 ± 0.84 SD mm (t = 15.9; p < 0.000001), consequently the eyelid positional asymmetry decreased from 3.1 ± 1.21 mm to 0.1 ± 0.86 SD mm (t = 16.5; p ≤ 0.000001). Twenty-nine percent of eyelids had mild contour abnormalities and 31.4% showed some degree of lash ptosis. Spontaneous blinks were abnormal in 93% of the cases (eyelids). The amplitude of the abnormal blinks ranged from 12.9% to 65.4% (mean = 37.1%) of the contralateral eyelids. Downward eyelid saccades were reduced in 79% of the eyelids. The amplitudes the saccades ranged from 2.2% to 84.6% (mean = 54.8%). Conclusions: In unilateral congenital ptosis, SMLPSr effectively reduces the positional asymmetry between eyelids. Mild contour abnormalities and lash ptosis are the main complications of the surgery. Postoperatively, spontaneous blinks and downward saccades were reduced in most eyelids. The reduced postoperative eyelid kinetics indicates that only patients with normal upward Bell signs are good candidates for this procedure.

Eyelid retraction, has received limited attention and it has passively been interpreted as the result of an overactive levator palpebrae superioris muscle secondary to midbrain injury. However, eyelid retractions can occur in other neurological diseases, not directly related with the midbrain. We report three patients who developed eyelid retraction. One patient had a bilateral eyelid retraction, related with Creutzfeldt-Jakob disease (CJD). Another patient had a unilateral right eyelid retraction associated with a thalamic-mesencephalic infarct. The third patient had a bilateral pontine infarction on magnetic resonance imaging. In the patient with CJD, eyelid retraction did not subside. Among patients with infarctions, the retraction persisted after focal symptoms had subsided, showing an evolution that was apparently independent of the basic process. The analysis of these patients allows us to conclude that the pathogenesis of eyelid retraction includes supranuclear mechanisms in both the development and maintenance of the phenomenon. Unilateral or bilateral eyelid retraction does not alter the normal function of eyelid, which ever had normal close eye blink. In these reported cases, a hyperactivity of levator palpebrae superioris muscle was clinically ruled out.

Transient ptosis is a known complication of botulinum toxin (BoNT) injection due to inadvertent migration of toxin into the levator palpebrae superioris muscle. Currently there is no treatment available for BoNT induced ptosis. Apraclonidine hydrochloride is a topical ophthalmic solution with selective alpha-2 and weak alpha-1 receptor agonist activity that has the ability to elevate the eye lid. Apraclonidine has been used as a diagnostic test in Horner's syndrome. We evaluated the effects apraclonidine in a cohort of BoNT induced ptosis and a patient with Horner syndrome. Each patient was administered 2 drops of apraclonidine 0.5% solution to the eye with the ptosis and was re-examined 20-30min later. All 6 patients showed improvement in ptosis. There was also improvement in ptosis in a patient with Horner's syndrome. Apraclonidine is not only useful as a diagnostic test in Horner's syndrome, but may be an effective and safe treatment for BoNT-induced ptosis.