Xinyu Zhou ,Fei Liu ,Yunyun Du ,Dongmei Li ,Tinxing Ouyng ,Jun Yng,*

a Department of Plastic and Reconstructive Surgery,Shanghai Ninth People’s Hospital,Shanghai Jiao Tong University School of Medicine,Shanghai 20001,China

b Shanghai Beaucare Clinics,Shanghai 200052,China

c Beijing Tongren Eye Center,Beijing Tongren Hospital,Capital Medical University,Beijing 100005,China

d Department of Plastic and Reconstructive Surgery,Xinhua Hospital,Shanghai Jiao Tong University School of Medicine,Shanghai 200092,China

Keywords:Blepharoptosis Correction Complication Consensus Diagnosis Treatment

1.Introduction

Blepharoptosis is a common disease that causes an unappealing appearance of the eyelid and impairs visual functions.1,2There are several well-established preoperative evaluations for blepharoptosis.3However,they are sometimes not fully understood by clinicians,resulting in incomplete assessments.Since the introduction of partial skin excision for the correction of blepharoptosis,more than 10 different approaches involving the manipulation of levator palpebrae superioris,frontalis,and Müller’s muscles have been reported.4-17Multiple surgical strategies can cause confusion regarding the optimal choice.Improper indications lead to unsatisfactory outcomes and a higher incidence of complications.18-22In recent years there has been a rapid expansion of the Chinese market for plastic and cosmetic surgery.Numerous novel approaches have emerged,followed by a large number of unexpected medical problems.To cope with adverse aspects and to improve medical quality,experts from four nationwide ocular plastic centers have reached a consensus on the diagnosis and correction of blepharoptosis after seven rounds of comprehensive discussion and revision with great support from the Society of Aesthetics and Plastic Surgeons of Chinese Medical Doctor Association.

The present consensus comprises diagnosis,ptotic grading,classification,preoperative evaluation,optimal surgical timing,intraoperative evaluation,surgical procedures,postoperative care,and management strategies in case of complications.Its purpose is to provide profound evidence to establish normative diagnosis and treatments for blepharoptosis repair,which ultimately benefits the patients.

2.Diagnosis and ptotic grading

Usually,the upper eyelid margin (UEM) covers the superior corneal limbus (SCL) within 2 mm of the primary gaze in normal eyes.If the covering value(CA),the distance between the UEM and SCL is more than 2 mm without the participation of the frontalis muscle,then true blepharoptosis can be confirmed.

For unilateral blepharoptosis,the dropping amount(DA)is equivalent to the difference between the palpebral fissure height (PFH) in the primary position of both eyes.For bilateral blepharoptosis,drooping is determined by the extent to which the UEM covers the SCL.In this case,CA=DA+2 mm.Blepharoptosis was classified as mild (CA ≤4 mm,DA ≤2 mm),moderate(4 mm ＜CA ≤6 mm,2 mm ＜DA ≤4 mm),and severe(CA ＞6 mm,DA ＞4 mm).

3.Etiology and classification

Blepharoptosis can occur in all age groups.It is a symptom and not a diagnosis.A thorough evaluation is required to determine the cause.Based on the different causative factors,blepharoptosis is classified into the following types.

3.1.Myogenic blepharoptosis

Myogenic blepharoptosis can be congenital or acquired.Congenital blepharoptosis is commonly caused by the dysgenesis of the levator palpebrae superioris,as well as disorders of the central and peripheral nerves which innervate the levator palpebrae superioris.23-25According to pathological findings,there was a decrease in the number or loss of striated muscle fibers replaced by fibrous tissue and fat.This loss positively correlated with the severity grading of blepharoptosis.A reduced systolic and diastolic function of the levator palpebrae superioris is present in myogenic blepharoptosis,while the latter may be the reason for postsurgical lid lag.Acquired blepharoptosis is usually attributed to local or generalized muscular diseases,such as myotonic syndrome,progressive muscular dystrophy,and myasthenia gravis.

3.2.Aponeurotic blepharoptosis

Dehiscence or disinsertion of the levator aponeurosis can lead to aponeurotic blepharoptosis.It is most common in some spontaneous or retrogressive diseases among the elderly,such as involutional blepharoptosis.Other causes include trauma,intraocular surgery,and corneal contact lenses.26-29The levator function (LF) in aponeurotic blepharoptosis is usually ＞8 mm,accompanied by the normal function of the superior rectus muscle.

3.3.Neurogenic blepharoptosis

Neurogenic blepharoptosis is caused by the paralytic oculomotor nerve or its branches,accompanied by the dysfunction of a single or multiple extraocular muscles.Patients usually present with blepharoptosis and malfunction of the superior rectus muscle.

Impaired sympathetic nerves in the cervical or the brainstem can cause systolic dysfunction of the Müller’s muscle,resulting in a narrower PFH.This is a common occurrence in Horner’s syndrome.2Marcus Gunn jaw-winking phenomenon30is a cranial dysinnervation disorder characterized by a variable degree of blepharoptosis in the resting and primary position.With jaw-winking,upper eyelid elevation (UEE),and instant wider PFH synchronously associated with the synkinetic movement of pterygoid muscle during mouth opening,chaw,and mastication.The mechanism behind this is thought to be aberrant central or infranuclear synkinesis between nerves innervating the pterygoid muscle and the levator palpebrae superioris or as a result of an abnormal connection between the motor branches of the trigeminal nerve and superior division branch of the oculomotor nerve innervating the levator palpebrae superioris.Currently,there is no optimal approach for the correction of the Marcus Gunn jaw-winking phenomenon.Before starting treatment,preoperative PFH and jaw winking must be accurately measured.Comprehensive communication with patients regarding perioperative management is important.Informed consent should be obtained from all participants.If jaw winking is within 2 mm,the treatment is similar to true blepharoptosis correction.Otherwise,correction of the ptotic eye is achieved after effective intervention and treatment of jaw winking.30,31

3.4.Mechanical blepharoptosis

Mechanical blepharoptosis is usually caused by trauma to the eyelid,tumor,or surgery,resulting in a thick scar on the eyelid and thus functional impairment of the levator palpebrae superioris.

3.5.Pseudoptosis

Pseudoptosis is not true blepharoptosis,it has an apparent ptotic appearance due to abnormalities in structures other than dysfunction of the levator muscle itself.The causes leading to pseudoptosis include enophthalmos,blepharospasm,thyroid-associated ophthalmopathy,and dermatochalasis.It is important to identify pseudoptosis and distinguish it from true blepharoptosis.

4.Preoperative assessments

Preoperative evaluations included marginal reflex distance (MRD),PFH,LF,eyelid elevation amount,frontalis muscle function,and Bell’s phenomenon.Other tests include visual acuity,refraction,extraocular motility,eye position,eye movement,pupillary examination,corneal sensation,and dry eye evaluation.32

4.1.Marginal reflex distance

MRD is a recognized and preferred parameter for evaluating blepharoptosis.It comprises MRD1and MRD2.33MRD1is the distance between the upper lid margin and the corneal light reflex,and MRD2is the distance between the corneal light reflex and the lower lid margin.Normally,MRD1+MRD2=PFH.This test was performed under light with frontalis action negated using a thumb to press the eyebrow.If the patient has poor LF(＜4 mm)without a clear exposure of the corneal light reflex,a negative MRD1(-MRD1)will be recorded with assistance from the examiner by elevating the upper eyelid.

4.2.Palpebral fissure height

PFH is an important parameter for the complete assessment of blepharoptosis.It is measured by calculating the distance between the upper eyelid margin and the lower eyelid margin at the center-line of the pupil,without the involvement of the frontalis action.

4.3.Levator function

LF is the amount of excursion measured on a millimeter-scale when the eyelid moves from an extreme downgaze to an extreme upgaze,with frontalis action negated by the thumb pressing above the eyebrow.The normal LF was recorded as being greater than 10 mm.It is postulated to be the most important measurement,as its value determines the required surgical procedure.34LF was graded as mild (LF ＜4 mm),moderate(4 mm ＜LF ＜7 mm),and severe(7 mm ＜LF ＜10 mm).

4.4.Upper eyelid elevation

It is particularly important to determine the desired lagophthalmos intraoperatively under general anesthesia.Upper eyelid elevation is quantitatively measured by calculating the excursion of the upper eyelid in the position of a downgaze and the primary gaze without frontalis action.

4.5.Bell’s phenomenon

Bell’s Phenomenon indicates the function of the superior rectus muscle and is evaluated while closing the affected eyes.3Positive Bell’s phenomenon is a self-protective action and is extremely important in blepharoptosis correction,especially in the early stage when patients present with incomplete closure of the eyelids.The patient was advised to close the eyes gently,and an attempt was made to open them to evaluate eye movement and corneal exposure.No movement and weak movement are designated as a negative Bell’s phenomenon and suspicious Bell’s phenomenon,respectively.In patients with poor Bell’s phenomenon,including the negative and suspicious Bell’s phenomenon,blepharoptosis should be undercorrected to avoid the risk of postoperative exposure keratopathy.

4.6.Frontalis muscle function

Frontalis muscle function can be measured as the amount of excursion of the frontalis muscle during a downgaze and an upgaze,with an indicating mark below the midpoint of the geisoma.It provides basic information that is required while performing manipulation of frontalis sling for severe blepharoptosis correction.

4.7.Eye position examination

Eye position examination is necessary pre-and postoperatively,to avoid changes in the position of the eye by blepharoptosis correction.The examination was conducted by first asking the patient to establish a primary gaze at a designed target 33 cm away from him/her,the eyes are then observed to ensure that they are symmetric and located at the midline.This was followed by the vision of one eye being blocked with an occluder to check the eye movement of the contralateral eye.Finally,the occluder was removed from the blocked eye and the eye movement was checked.Any aberrant eye movement,including strabismus,was recorded.

4.8.Eye movement inspection

Eye movement inspection is important for pre-and-post-surgically.The examination was performed by placing a light 33 cm away from the patient with his head fixed,guiding and checking the eye movement from six diagnostic directions controlled by the six extraocular muscles,and recording the distances between the eyelid margin and corneal limbus.The function of the superior rectus muscle was emphasized.When the inferior corneal limbus is located below the line connecting the inner canthus and the outer canthus,a weak function of the superior rectus muscle is indicated.Undercorrection is expected in this type of situation.

5.Surgical timing

The choice of surgical timing is determined according to the different causes and the severity grading of blepharoptosis.

5.1.Surgical timing for congenital blepharoptosis

Mild to moderate blepharoptosis can be corrected under local anesthesia at a later stage when the patient has grown up,and as the pupil can be completely or mostly exposed,it is rare for them to develop from deprivation amblyopia.Considering the social and psychological factors,blepharoptosis can be repaired at preschool age(3-5 years old).

Patients with severe unilateral blepharoptosis usually have an obvious visual block with a chin up and head tilt posture.This requires early surgery (≥1-year-old) to avoid form-deprivation amblyopia and vertebral dysplasia.35,36

The blepharophimosis-ptosis-epicanthus inversus syndrome is also known as the blepharophimosis syndrome,which displays severe eyelid blepharoptosis.Two-staged surgical correction is recommended,starting at 2 years of age.Blepharoptosis repair is expected 6-12 months after medial and lateral canthoplasties.

For bilateral blepharoptosis with different levator functions,the ptotic symptom usually aggravates in the eye after the contralateral eye is corrected because of the Hearing’s law.Therefore,repair surgery for the eye with better levator function is recommended at least 6 months after the first surgical correction for the contralateral eye with relatively worse levator function.37,38

5.2.Surgical timing for acquired blepharoptosis

In traumatic blepharoptosis,the levator muscle is usually injured and requires immediate repair.If there was no chance for primary repair or ifit had already been a while since the injury had taken place,surgical correction is expected at 6-12 months after complete wound healing and maturation of the local scar,if there is no improvement in blepharoptosis.

For aponeurotic blepharoptosis,once the diagnosis is confirmed,repair surgery should be performed without delay.For blepharoptosis caused by the paralysis of the oculomotor nerve,myasthenia gravis,and other non-inherent factors,surgical correction is expected at least 6 months after complete stabilization of the primary disease.

6.Evaluation of intraoperative eyelid elevation

Under local anesthesia,the upper eyelid margin of the affected eye in cases of unilateral blepharoptosis is recommended to be 1 mm higher than the contralateral eyelid immediately after surgery in a seated position.In bilateral blepharoptosis,the upper eyelid margin should be 1 mm below the superior corneal limbus immediately after surgery.

Under general anesthesia,it is also important to determine the desired lagophthalmos during surgery.In unilateral blepharoptosis,the desired lagophthalmos is equivalent to the excursion difference between the affected and unaffected eyes when in the position of a downgaze and a primary gaze.In bilateral blepharoptosis,the desired lagophthalmos plus UEE was 9 mm.If Bell’s phenomenon is negative,the desired lagophthalmos is recommended to range from 5 mm to 7 mm.If the repair of blepharoptosis involved manipulation of the frontalis muscle,the upper eyelid margin is also supposed to be 1 mm below the superior corneal limbus immediately after surgery.

7.Choice of surgical procedures

7.1.Levator-based procedures

Levator-based procedures include levator advancement,levator placement,and levator resection.They are deemed as the most physiological approaches for blepharoptosis repair.However,these procedures may result in the under-correction of severe blepharoptosis repair due to very poor levator function.

7.2.Frontalis-Based Surgery

Frontalis-based surgery is commonly performed in patients with congenital severe blepharoptosis with poor levator function(＜4 mm),or in patients with penetrating injury to the levator muscle caused as a result of trauma,surgery,or any other reason.It is also useful in adults for the repair of myasthenia gravis,chronic progressive external ophthalmoplegia,and the 3rd nerve palsies.Surgical procedures include the frontalis muscle flap,frontalis muscle fascial flap,and frontalis sling surgeries.The suspension materials used may be autologous or allogeneic.

7.3.Müller’s muscle-conjunctival resection

This posterior approach technique is useful for patients presenting with mild blepharoptosis.17,39and blepharoptosis secondary to Horner’s syndrome,with good levator function.Müller’s muscle is not only a mimetic muscle but also a smooth muscle innervated by the sympathetic nerve.When performing Müller’s muscle-conjunctival resection(MMCR),the adequacy of healthy conjunctiva in the superior fornix and local anesthetic solution without epinephrine for transconjunctival injection has to be ensured.

7.4.Tarsectomy-based procedures

The upper eyelid can be elevated to achieve improved PFH and appearance through proper tarsectomy.This procedure is effective not only for the correction of mild blepharoptosis but also for the repair of moderate blepharoptosis and severe blepharoptosis in combination with levator resection.However,a tarsus width of at least 5 mm must be retained to avoid potential complications.The tarsus is a supporting structure for the eye.Besides,lipids secreted by the meibomian glands are important for maintaining the function of lacrimal firms.The amount of lacrima,required for tear stabilization and compensation,that could be influenced after tarsectomy needs to be further investigated.40,41

7.5.Levator resection combined with Conjoint fascial sheath

Conjoint fascial sheath(CFS),also known as the Check ligament,is a structure of the levator palpebrae superioris and superior rectus muscle attached to the conjunctival fornix,located in the intermuscular space between the anterior one-third of the superior rectus muscle and segment of levator palpebrae superioris.For correction of severe blepharoptosis,CFS can be suspended in the tarsus to strengthen the elevation of the upper eyelid.The driving force of CFS comes predominantly from the superior rectus muscle.If the CSF is manipulated,intraoperative dysfunction of the superior rectus muscle may occur,this needs to be avoided as it may even lead to postoperative diplopia and katotropia.

To summarize,the choice of surgical procedure mainly depends on the levator function.Levator plication and levator resection are usually planned to correct mild blepharoptosis with LF ≥7 mm.Tarsectomy and MMCR have also been reported to be effective.For the correction of moderate blepharoptosis with 4 mm ＜LF ＜7 mm,a levator resection procedure is recommended to achieve satisfactory outcomes.To correct severe blepharoptosis with LF ＜4 mm,the levator resection procedure was initially attempted.If undercorrection is observed,a tarsectomy is applied for combined repair.If undercorrection is still present,CFS suspension has to be performed for further elevation.However,if a satisfactory repair cannot be achieved using the aforementioned combinedtriple procedures of levator resection,tarsectomy,and CFS suspension,or preoperatively measured LF is less than 1 mm,manipulation of frontalis-based surgeries is considered to be involved.42-44

Surgical procedures can also be determined based on the desired UEE,which is usually evaluated preoperatively.If the levator advancement fails to achieve the desired UEE,levator resection will be performed.If undercorrection is still present,combined surgery involving levator resection and tarsectomy,or levator resection,tarsectomy,and CFS suspension will be relied upon.The combined-triple approach is useful for different types of blepharoptosis,including the majority of severe blepharoptosis.45,46

8.Postoperative care

For patients with weak or negative Bell’s phenomenon or incomplete eye closure (≥2 mm) immediately after surgery,an eye ointment is applied followed by the Frost suture closing the eyes.An ice pack was necessary for 48 h post-surgery to minimize swelling and for pain relief.The dressing gauze was removed 3 days after surgery,followed by eye drops 4 times a day and application of eye ointment combined with Frost suture at night until no exposed corneal was observed when the patient slept during the night.Eye drops for regeneration and repair of the cornea are required when exposure keratopathy occurs as a result of poor or improper postoperative care.

9.Complications and management

Blepharoptosis repair is very complicated,with a high incidence of various complications.Usually,multiple operations are necessary to achieve satisfactory esthetic outcomes.Because of this,comprehensive communication with patients and signed consent forms are required.Here,we summarize the common complications,their clinical presentations,possible causes,and relevant management strategies(Table 1).

Table 1 Complications,clinical presentations,causes,and management strategies for blepharoptosis-related surgeries.

Table 1 (continued)

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

Liu F,Du Y,and Zhou X:Writing-Original draft.Yang J,Li D,and Ouyang T:Conceptualization,Supervision,Writing-Reviewing and Editing.

Acknowledgements

Doctors from other institutions participated in the finalized version of the consensus and contributed much to this work.Here is their information listed in alphabetical order of their family names:Chuan Cao(Department of Plastic Surgery,Southwestern Hospital,the third Military Medical University),Gang Chen(Department of Plastic Surgery,Jiangsu Province Hospital of Chinese Medicine),Hua Chen (Department of Plastic and Burn Surgery,Inner Mongolia Medical University Hospital),Wenli Chen(Department of Medical Cosmetology,Tianjin Eye Hospital),Jian Cheng(Hangzhou Victoria Medical Beauty Hospital),Xianglin Dong(Department of Plastic Surgery,the First Affiliated Hospital of Xinjiang Medical University),Chuanbo Feng(Department of Plastic and Cosmetic Surgery,Nanfang Hospital,Southern Medical University),Hui Gao(Plastic and Cosmetic Center,the People’s Hospital of Shijiazhuang),Shu Guo(Department of Plastic Surgery,the First Affiliated Hospital of China Medical University),Xiaobo Guo (Department of Burn and Plastic Surgery,Guizhou Provincial People’s Hospital),Xiaolei Jin (16th Department,Plastic Surgery Hospital,Chinese Academy of Medical Sciences,Peking Union Medical College),Xiaolin Li (Department of Plastic and Maxillofacial Surgey,Jiangxi Provincial People’s Hospital),Furong Liu(Chengdu ReYee Perfection Cosmetic Clinic),Xusong Luo(Department of Plastic and Reconstructive Surgery,Shanghai Ninth People’s Hospital,Shanghai Jiao Tong University School of Medicine),Ying Liu (Department of Plastic and Reconstructive Surgery,Shanghai Ninth People’s Hospital,Shanghai Jiao Tong University School of Medicine),Shaolin Ma(Department of Plastic Surgery,the First Affiliated Hospital of Xinjiang Medical University),Yan Ma(Division of Plastic Surgery,Xinjiang Korla Bazhou People’s Hospital),Jun Tan (Department of Plastic and Laser Esthetic Surgery,the People’s Hospital of Hunan Province),Qian Tan(Department of Burns and Plastic Surgery,Affiliated Drum Tower Hospital of Nanjing University Medical School),Qiying Wang(Department of Plastic Surgery,the First Affiliated Hospital of Zhengzhou University),Hong Xiao (Department of Plastic Surgery,The Second Affiliated Hospital of Kunming Medical University),Wei Xiong (Department of Burn and Plastic Surgery,the First Affiliated Hospital of Shihezi University),Feng Yang (Department of Plastic Surgery,the Second Affiliated Hospital,University of South China),Yangyan Yi (Department of Plastic and Cosmetic Surgery,the Second Affiliated Hospital of Nanchang University),Ping Yu (Xinjiang Plastic Surgery Hospital),Yongsheng Zheng(Department of Plastic and Cosmetic Surgery,Beijing Tongren Eye Center),and Yuguang Zhang (Department of Plastic and Reconstructive Surgery,Shanghai Ninth People’s Hospital,Shanghai Jiao Tong University School of Medicine).We also thank Dr.Guoying Song from the Chinese Medical Journal Editorial Board for his kind help and support in our work.