Evaluation of Long-Term Functional and Aesthetic Results to use a Single Rhomboid-Shaped Fascial Strip for Severe Congenital Unilateral Blepharoptosis

Background

Surgery for congenital blephaloptosis is often performed at about 4-5 years of age. Long-term follow-up is important during facial growth. We performed frontal suspension using a single rhomboid-shaped autogenous fascial strip. We conducted a long-term evaluation of severe congenital unilateral blephaloptosis patients.

Patients and Methods

334 patients with congenital blepharoptosis underwent primary surgery in our department between 1994 and 2006. Of these, 192 patients had unilateral congenital blepharoptosis with levator function of 3 mm or less on the affected side. All patients received consultation with a pediatric ophthalmologist and were referred to our department. All patients had normal corneal sensation and the normal Bell phenomenon. Patients with blepharophimosis syndrome were excluded from this study, as were those without photographs and examinations for at least 10 years.

The functional evaluation included the measurement of visual acuity (log MAR), palpebral fissure height (PFH), and marginal reflex distance (MRD) on photographs to compare both eyes preoperatively and postoperatively. Visual acuity was evaluated for patients with laterality. PFH was assessed as the ratio of the right and left eyes, and the ratio of MRD1 and 2 (= MRD ratio) was used in the evaluation. Morphological evaluation was based on patient and family comments. The patients were also asked to state their satisfaction and complaints. The surgical results were evaluated as being excellent, good, fair, poor, or other according to our criteria:

Results

There were 95 patients. Left ptosis was present in 43 patients and right ptosis in 52 patients. Mean age at the time of operation was 4.8years (range 3.5-7.4 years). The follow-up period was 10 to 12 years. Fifty-eight patients had laterality, for whom preoperative and postoperative vision results were recorded. Evaluation of the log MAR ratio of the affected side showed improvements in visual acuity (mean ± S.D.: preoperatively 0.25 ± 0.161, postoperatively 0.085 ± 0.120, p < 0.001). The postoperative MRD ratio of the affected eye was significantly improved compared to that before surgery (preoperatively 0.021 ± 0.0135, postoperatively 0.611 ± 0.0131, p < 0.001), but it did not reach the value of the MRD ratio of the unaffected eye (preoperatively 0.704 ± 0.0418, postoperatively 0.663 ± 0.0430).

No clinically significant difference in postoperative PFH was seen when comparing the affected side and unaffected side as a ratio (preoperatively 0.367 ± 0.258, postoperatively 0.925 ± 0.171). Of 95 patients with unilateral ptosis, the surgical results were excellent in 62, good in 14, fair in 12, poor in 3, and other in 4 patients. Patient dissatisfaction resulted from various outcomes, including trichiasis, large differences in the left-right visual acuity, and strabismus. No major complications occurred. Aesthetic and functional results were good, with a patient satisfaction rating of 80%. Secondary surgery was performed in 17 of 19 patients with an unfavorable outcome.

Conclusion

Based on our evaluation, our surgical procedure appears useful for patients with unilateral congenital ptosis. Moreover, blephaloptosis surgery is useful for improving visual acuity. We report this surgical procedure and discuss the long-term results.