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The frontalis sling operation using silicone rod for ptosis correction in chronic progressive external ophthalmoplegia. (A) Indication of five horizontal stab incisions, three above the eyebrow, two 3 mm above the eyelid. (B) Two 6-0 polypropylene sutures pre-placed within the stab incisions, passing the tarsal plate in partial thickness. (C) Passage of the silicone rod through the two eyelid incision sites with indication of the previously placed 6-0 polypropylene sutures. (D) Passage of the medial and lateral ends of the silicone rod through the orbital septum toward the nasal and temporal incisions. (E) Exit of both ends of the silicone rod through the central apex incision. (F) Ends of the silicone rod brought within a silicone sleeve. (G) Completion of the surgical procedure with skin closure. 

The frontalis sling operation using silicone rod for ptosis correction in chronic progressive external ophthalmoplegia. (A) Indication of five horizontal stab incisions, three above the eyebrow, two 3 mm above the eyelid. (B) Two 6-0 polypropylene sutures pre-placed within the stab incisions, passing the tarsal plate in partial thickness. (C) Passage of the silicone rod through the two eyelid incision sites with indication of the previously placed 6-0 polypropylene sutures. (D) Passage of the medial and lateral ends of the silicone rod through the orbital septum toward the nasal and temporal incisions. (E) Exit of both ends of the silicone rod through the central apex incision. (F) Ends of the silicone rod brought within a silicone sleeve. (G) Completion of the surgical procedure with skin closure. 

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The aim of the study was to evaluate the results of the frontalis sling operation using silicone rod for the correction of ptosis in chronic progressive external ophthalmoplegia patients. Chronic progressive external ophthalmoplegia patients who received the frontalis sling operation using silicone rods from 1999 to 2006 were included in this study...

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... was performed under local anaesthesia. The upper eyelid, brow and lower forehead were injected with 2% lidocaine mixed with 1:100,000 epinephrine (adrenaline). The operative steps are described in fig 1. Five horizontal incisions were made in the shape of a pentagon -three above the eyebrow and two 3 mm above the upper eyelid margin. Two small horizontal stab incisions were made at the upper eyelid margin and dissection through the orbicularis muscle was carried out until the tarsal plate was exposed. Two 6-0 polypropylene sutures were pre-placed within the stab incisions, passing the tarsal plate in partial thickness. The Wright fascia needle was passed just above the tarsus, resultantly placing the silicone rod (Visitec, BD Ophthalmics, New Jersey, USA) under the pretarsal orbicularis muscle, and the silicone rod was fixated to the tarsus by tying the previously placed polypropylene sutures. The medial and lateral ends of the silicone rod were passed through the orbital septum toward the nasal and temporal brow incision respectively and redirected, subcutaneously, toward the central apex incision with the Wright fascia needle. The ends of the silicone rod were brought together within a silicone sleeve and the eyelid was pulled group.bmj.com on December 23, 2009 -Published by bjo.bmj.com Downloaded from up until the intraoperative MRD was +1.0 mm. The silicone sleeve was tied with 6-0 polypropylene sutures and placed in the central apex ...

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... Monofilament nylon, poly-filament sutures, silicone rods, allogenic and autogenous fascia lata, temporal fascia and palmaris longus tendons have been used. [8][9][10][11] It is our belief‚ from our experience, that autogenous materials are far more reliable due to various reasons. In fact, the recurrence rate and complication of infections and granulomas were found to be quite high in pediatric blepharotosis correction, due to the fact many are being done using nonautogenous materials. ...
Article
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Acquired eyelid ptosis in adults, with complete loss of levator palpebrae superiosis function, can be a challenging problem to diagnose and treat. A 48-year-old woman with chronic bilateral severe blepharoptosis of 10 years duration is presented, whose neurological investigations excluded myasthenia gravis. The patient was preliminarily diagnosed with chronic progressive external ophthalmoplegia. The levator excursion was negligible, and a frontalis suspension procedure was considered using a conventional autogenous fascia lata graft. An optimal outcome was achieved with over 16-years follow-up. Although the patient was healthy otherwise upon first presentation, 10 years later, she developed other neurologic manifestations, including dysphagia and oral dryness. The fact that blepharoptosis did not recur over the years in this case differentiates an oculo-pharyngeal type of muscular dystrophy in this patient from other types and from the more frequent condition of chronic progressive external ophthalmoplegia.
... However, because of the limited upgaze in patients with 3rdNP, many show poor Bell's phenomenon, making the cornea vulnerable to exposure keratopathy after the surgery. Among the many suspension materials currently used for frontalis sling operations, silicone rods offer good elasticity for favorable eyelid blinking and simple adjustability in revision surgery [4,5]. Therefore, frontalis sling surgery using a silicone rod could be a good treatment option in managing severe ptosis due to 3rdNP in cases showing the possibility of postoperative corneal complications. ...
... Second, the silicone rods have superior adjustability. The rods are not incorporated into the surrounding tissues and allow easy adjustment of eyelid height after the surgery [5,27]. Third, the silicone rods have a long shelf life and are less susceptible to infection. ...
Article
Purpose: To evaluate the results of the frontalis sling operation using a silicone rod for the correction of ptosis in patients with third nerve palsy with a focus on corneal safety. Methods: Patients with third nerve palsy who underwent the frontalis sling operation using a silicone rod between 2008 and 2019 were included in this study. The medical records of all patients were reviewed, and their clinical characteristics and postoperative outcomes were analyzed. In this retrospective, interventional case series, the main outcome measures were eyelid contour, eyelid height by margin reflex distance (MRD), and corneal status. Results: Twenty-four eyes of 18 patients (12 males and six females) were included. The mean age at the time of surgery was 35.1 years (range, 5-64 years). Twelve patients underwent a unilateral ptosis operation and six patients received a bilateral ptosis operation. The mean follow-up period was 32.1 months (range, 2-87 months). Most patients (21 of 24 eyes, 88%) showed poor Bell's phenomenon on preoperative examination. Satisfactory eyelid height and eyelid contour were achieved in almost all patients (mean postoperative MRD: +1.2 mm) postoperatively. Although corneal erosions were detected for several months in eight of 24 eyes after surgery, these findings were well controlled medically with artificial tear eye drops and ointments. Conclusions: Frontalis sling surgery using a silicone rod can safely and effectively correct ptosis without severe corneal complications in patients with third nerve palsy. Our study outlines a new method to define the postoperative safety outcome by specifically focusing on categorized corneal status.
... Frontalis suspension is a great option for severe ptosis with levator function of 4 mm or less [ Figure 3]. It has been successfully employed in many etiologies of myogenic and neurogenic ptosis, including isolated congenital myogenic ptosis, BPES, OPMD, CPEO, Marcus Gunn jaw-winking, and CN-III palsies [34,134,[139][140][141][142] . The frontalis muscle is bridged to the superior tarsal plate and epitarsal tissue to allow for improved eyelid position in primary gaze. ...
Article
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Blepharoptosis is present when the upper eyelid is lower than its normal anatomic position in primary gaze. This is secondary to a neuromuscular imbalance with weakening of the upper eyelid retractors in relation to the protractors. As the degree of ptosis worsens, significant functional and cosmetic concerns often arise. To adequately address these concerns, ptosis is divided into categories based on the underlying pathogenesis: aponeurotic, myogenic, neurogenic, mechanical, or traumatic. Within these categories, it is important to determine if the ptosis is congenital or acquired as diagnostic and therapeutic approaches often vary between these two distinctions. The goal of this review is to summarize the classification, evaluation, management, and potential pitfalls of both acquired and congenital ptosis.
... [18] Due to levator palpebrae superioris (LPS) weakness, ptosis can be observed and quantified as reduced upper lid excursion that is typically <7 mm. [19,20] As ptosis progresses, patients compensate by adopting a chin-up anomalous head posture and frontalis overaction. Weakness of LPS may also be accompanied by weakness of orbicularis oculi such that patients also develop lagophthalmos or involutional ectropion. ...
... [21] While several case series report the use of fascia lata for frontalis suspension, [21,24] there is a theoretical benefit of using silicone slings, as this material facilitates postoperative adjustment or reversal. [19,20] In all cases, the extent of upper lid elevation should be titrated cautiously. [24] Surgery is not advisable in patients with severe orbicularis oculi weakness. ...
Article
The visual system has high metabolic requirements and is therefore particularly vulnerable to mitochondrial dysfunction. The most commonly affected tissues include the extraocular muscles, photoreceptors, retinal pigment epithelium, optic nerve and visual cortex. Hence, the most common manifestations of mitochondrial disorders are progressive external ophthalmoplegia, macular pattern dystrophy, pigmentary retinopathy, optic neuropathy and retrochiasmal visual field loss. With the exception of Leber hereditary optic neuropathy and stroke-like episodes seen in mitochondrial encephalopathy, lactic acidosis and stroke-like episodes, the majority of neuro-ophthalmic manifestations have an insidious onset. As such, some patients may not recognize subtle progressive visual symptoms. When mitochondrial disorders are highly suspected, meticulous examination performed by an ophthalmologist with targeted ancillary testing can help confirm the diagnosis. Similarly, neuro-ophthalmic symptoms and signs may be the first indication of mitochondrial disease and should prompt systemic investigations for potentially life-threatening associations, such as cardiac conduction defects. Finally, the ophthalmologist can offer symptomatic treatments for some of the most disabling manifestations of these disorders.
... 15 Despite the risk of corneal exposure, traditional procedures such as levator advancement or resection and frontalis suspension have been advocated for the correction of myopathic ptosis. 11,[16][17][18][19][20][21][22][23][24][25] However, in some series it is difficult to interpret the results because >1 technique was used, including anterior aponeurotic advancement, brow suspension, and Fasanella-Servat procedures. 11,18,25 Several surgeons have suggested that brow suspension with silicone rods is the most appropriated surgery for the management of these challenging cases. ...
... Moreover, in all series of silicone suspension in myopathic patients a variable percentage of patients developed chronic superficial keratopathy which in some cases progressed to corneal abscess. 19,20,22,23 Another option that deserves to be considered in selected cases is the combination of upper eyelid ptosis surgery with elevation of the lower eyelid margin. This procedure was formally proposed in 1987 by Holck et al. 26 who used a combination of scleral graft to lift the lower eyelid margin with levator resection or frontalis suspension. ...
Article
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Purpose: To report the effect of frontalis linkage without intraoperative eyelid elevation for the management of myopathic ptosis. Methods: Retrospective analysis of 21 (42 eyelids) myopathic patients with bilateral ptosis who were operated between 1999 and 2017. All patients had orbicularis weakness and poor or absent Bell's phenomenon. Surgery consisted of using an autogenous fascia sling to link the tarsal plate to the frontalis muscle without any degree of intraoperative eyelid elevation. The main outcome measures were margin reflex distance, brow height and degree of brow excursion and degree of lagophthalmos, and exposure keratitis. Results: After surgery, there were significant changes (p <0.0001) in both margin reflex distance and brow position. Mean margin reflex distance increased to 1.4 mm ± 1.34 DP and with full frontalis contraction, it reached 3.0 mm ± 1.73 DP, while mean brow position decreased 1.6 mm ± 1.59 SD, p < 0.0001. Postoperative lagophthalmos was not detected in 31 (74%) eyes. In the remaining 11 eyes (26%), lagophthalmos ranged from 1.2 to 5.2 mm (mean = 1.7 mm ± 0.74 DP). Mild inferior superficial keratitis was detected in 14 eyes (33.3%) of 7 patients only 3 of which had lagophthalmos. One patient needed additional surgery to correct unilateral eyelid retraction. Overall, 81.81% of the patients were pleased with the procedure. Conclusions: Myopathic ptosis can be alleviated with a minimal amount of lagophthalmos by just linking the tarsal plate to the frontalis muscle without lifting the eyelid margin intraoperatively.
... The materials available for this purpose are autogenous and preserved fascia lata, temporalis fascia, deepithelialized strips of skin, orbicularis oculi muscle, palmaris longus tendon, silicone rods, nonabsorbable suture materials (nylon/polypropylene/polyester), and wide porous expanded polytetrafluoroethylene. [1,2] Of these, silicone has the distinct advantage of excellent elasticity enabling good blinking movement, easy adjustability in case of revision, or simple removal of the sling at a later date if warranted. [1,3] Postoperative lagophthalmos after frontalis suspension surgery is almost universal and predisposes the development of corneal complications in vulnerable patient groups. Clinical findings in patients associated with third cranial nerve palsy, ocular myasthenia gravis (OMG), and chronic progressive external ophthalmoplegia (CPEO) are ptosis, extraocular movement disorders, weak orbicularis action, poor Bell's phenomenon, and poor lid closure. ...
Article
Full-text available
PURPOSE The purpose of the study was to evaluate the efficacy of silicone rods as frontalis sling for correction of ptosis associated with poor Bell's phenomenon in specific situations. MATERIALS AND METHODS A retrospective interventional case series of 25 eyes of 19 patients who underwent frontalis suspension surgery with silicone rods for ptosis correction from May 2006 to April 2011, was performed. Inclusion criteria included severe ptosis with poor Bell's phenomenon. Patient evaluation included clinical history and other relevant parameters of ptosis measurement. Final outcome measurements included postoperative lid height, lagophthalmos, complications, need for reoperation, and patient satisfaction. RESULTS Mean age at presentation was 25.72 ± 2.2 years. The sex ratio of male: female was 1.11. The causes of ptosis included chronic progressive external ophthalmoplegia (CPEO) in 11 eyes (44%), oculopharyngeal dystrophy in 2 (8%), third cranial nerve palsy in 7 (28%), traumatic in three eyes (12%), and iatrogenic postoperative ptosis (after orbital tumor excision) in two eyes (8%). The postoperative palpebral fissure height and margin reflex distance improved significantly (P = 0.0001). Extrusion of the sling and granuloma formation occurred in two eyes each, and these patients had to undergo sling removal. One patient developed mild exposure keratopathy and was managed conservatively. CONCLUSION Silicone is an effective material for use in frontalis suspension in the management of severe ptosis with poor Bell's phenomenon. The elastic nature of silicone rod makes it an ideal suspensory material for patients with CPEO or third nerve palsy.
... A hallmark exam feature of PEOrelated ptosis is poor function of the levator palpebrae superioris (LPS) muscle. Whereas the normal excursion of the superior eyelid from maximal downgaze to upgaze with stabilization of the brow is ≥12 mm, PEO patients often have less than 8-10 mm of function [9,10]. ...
... Poor Bell's phenomenon related to weakness of the superior recti muscles and impaired orbicularis oculi strength with incomplete blink response places PEO patients at higher risk for corneal exposure and severe dryness following frontalis suspension procedures. Aggressive post-operative lubrication is often required [9]. ...
Article
Full-text available
Progressive external ophthalmoplegia (PEO), marked by progressive bilateral ptosis and diffuse reduction in ocular motility, represents a finding of mitochondrial myopathy rather than a true diagnosis. PEO often occurs with other systemic features of mitochondrial dysfunction that can cause significant morbidity and mortality. Accurate and early recognition of PEO is paramount for the optimal care of these patients. We present an evidence-based review of the presenting neuro-ophthalmic features, differential diagnosis, diagnostic tools, systemic implications, and treatment options for isolated PEO and other PEO-associated mitochondrial syndromes.
... The efficacy of these procedures has been reported in several studies. [1][2][3] In patients with myopathic ptosis, ocular motility is often impaired and the orbicularis muscle can be weak, resulting in a poor or absent Bell's phenomenon, which increases the risk of postoperative lagophthalmos. In addition, myopathies causing ptosis are often progressive, with increasing risk of corneal exposure problems over time. ...
Article
Full-text available
Purpose: The surgical management of myopathic ptosis remains a challenge. The authors report the results of a modified posterior approach tarsal switch technique, which raises both the upper and lower eyelids and reduces the risk of corneal exposure in these patients. Methods: A modified tarsal switch technique is described. A tarsoconjunctival and Muller's muscle graft is harvested via a posterior approach from the upper eyelid, the defect closed, and the graft transferred to the lower eyelid. Results: The procedure was performed on 16 eyelids of 9 patients. No adjunctive procedures were performed. The patients ranged in age from 36 years to 79 years. All patients had bilateral myopathic ptosis, reduced levator function, and a poor Bell's response. The margin reflex distance-1 increased by 1.5 to 4.5 mm (mean 2.3 mm) and the margin reflex distance-2 decreased by 0.5 to 2.5 mm (mean 1.6 mm). There were no intraoperative complications, no significant corneal exposure problems, and no patients required revision surgery over a follow-up period of 6 to 52 months (mean 16 months). Conclusions: This technique of harvesting the tarsoconjunctival-Muller's muscle graft posteriorly, closing that defect and transferring the graft into the lower eyelid to elevate it, is an effective surgical procedure for the management of ptosis in patients with poor ocular protective mechanisms.
... Other choices of sling materials include nonautogenous materials like silicone rods. Elastic nature of silicone rods allows good eyelid approximation, minimizes lagophthalmus and corneal exposure, and it is easy to remove it in case of exposure keratopathy which usually occurs in CPEO patients (6). Palmaris longus tendon can be also used as sling material like other tendons. ...
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... A proportion of patients with CPEO develop significant ptosis that obscures visual field. Corrective ptosis surgery such as frontalis sling operation improves the functional and cosmetic outcome in selected patients [3]. ...
Article
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Mitochondrial disease is one of the most common groups of genetic diseases with a minimum prevalence of greater than 1 in 5000 in adults. Whilst multi-system involvement is often evident, neurological manifestation is the principal presentation in most cases. The multiple clinical phenotypes and the involvement of both the mitochondrial and nuclear genome make mitochondrial disease particularly challenging for the clinician. In this review article we cover mitochondrial genetics and common neurological presentations associated with adult mitochondrial disease. In addition, specific and supportive treatments are discussed.