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AAMJ, Vol. 8, N. 3, Sep, (Suppl), 2010
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ASSESSMENT OF SILICON FRONTALIS SLING FOR
CORRECTION OF SEVERE CONGENITAL PTOSIS WITH
POOR LEVATOR MUSCLE FUNCTION
Mahmoud Abd El-Badie Mohamed
Ophthalmology Department, Faculty Of Medicine Al-Azhar University –Assiut
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ABSTRACT
PURPOSE:To evaluate the efficacy and outcomes of silicon frontalis
suspension by Fox pentagon for correction of severe congenital ptosis with
poor levator function. METHODS Thirty-nine eyelids with congenital ptosis in
30 patients(21 patients with unilateral ptosis and 9 patients with bilateral
ptosis) were repaired using the frontalis silicon rod sling. Lid height, contour,
Lid crease position, lagophthalmos, corneal exposure and other complications
were assessed in all the patients. The postoperative cosmetic outcome was
graded into good, fair or poor. Postsurgical evaluation was performed at 1
week, 2 weeks, 1 month, 3 months and at 6 months post operative. RESULTS:
Margin reflex distance (MRD) increased an average of 2.5 ± 0.91 mm, from a
mean preoperative of 0.4 ± 0.22 mm with P-value less than 0.05. Postoperative
34 (87.18%) eyes had good correction. Four eyes (10.26%) had fair correction
and 1 eye (2.56%) had poor correction. Lagophthalmos occurred in 9 eyes
(23.07%). Recurrence occurred in one eye. CONCLUSION: The procedure
with Silicone Frontalis Sling is easy, fast, and leads to less tissue trauma and
less rate of recurrence.
INTRODUCTION
The objective of ptosis surgery is to obtain the best possible functioning
and cosmetic results. The ideal surgical treatment and age of intervention were
(1)
controversial in the management of congenital ptosis .
Factors including the severity of ptosis, degree of head posture, presence or
absence of levator muscle function, patient's age and the presence of
amblyopia. For this reason, repair of ptosis is indicated as soon as the diagnosis
is made. Frontalis suspension of the upper lid is an effective and simple method
(2)
of treatment .
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Mahmoud Abd El-Badie Mohamed
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Frontalis suspension is a commonly used surgery that is indicated in
patients with blepharoptosis and poor levator muscle function. This surgery
connects the eyelid to the brow with a sling material and utilizes the power of
the frontalis muscle to elevate the poorly functioning eyelid. Frontalis
suspension surgery is now well accepted as the procedure of choice for patients
(congenital or acquired etiologies) with severe ptosis and poor levator function
(3)
.
Many suspension materials hade been used. These include autogenously
(4) (5) (6)
and preserved fascia lata , sclera , non-absorbable sutures , suture
(7)
reinforced sclera, temporalis fascia , Gore-Tex strips and silicone bands and
(8)
rods .
MATERIAL AND METHODS
Thirty-nine ptotic eyelids in 30 patients were corrected using the
frontalis silicon rod sling.
Inclusion criteria:
Severe congenital ptosis with poor levator function i.e. upper lid margin and
pupillary reflex distance (MRD 1) < 1 mm with poor levator function < 4mm.
Exclusion criteria:
1- Mild or Moderate congenital ptosis (MRD 1 >1mm).
2- Absent Bell’s phenomenon.
Preoperative evaluation:
1-Detailed history:
Birth history to reveal traumatic factors during labour, family history may be
helpful in identifying cases of blepharophimosis syndrome, orbital fibrosis
syndrome, mitochondrial myopathies, and muscular dystrophy.
A history of diurnal fluctuation may point to myasthenia gravis as a possible
cause of ptosis, which is then confirmed by analyzing serological antibodies
and by the edrophonium (tensilon) test.
2- Eyelid examination:
The margin reflex distance-1 (MRD-1) is the distance from the upper eyelid
margin to the light reflex on the cornea, levator function, Bell’s phenomenon,
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Hering’s law, lagophthalmos, eyelid crease position, eyelid lag, epicanthus and
telecanthus, jaw-wink phenomenon, scar (previous trauma or surgery).
3- A general ophthalmic examination, which is done before the operation, to
unveil anisocoria in Horner’s syndrome or third nerve palsy. Refraction and
BCVA to detect amblyopia. Amblyopia was defined as best-correct visual
acuity of less than 20/40, and greater than 2 Snellen's lines of difference
between the 2 eyes. In younger patients amblyopia was defined by a lack of
fixation in the ptotic eye compared with the nonptotic one.
4- Head and neck examination for abnormal head position and brow elevation.
5- General examination, blood test, thyroid function tests, acetylcholin receptor
antibody, computed tomography or magnetic resonance image and
edrophonium test.
Surgical technique:
The surgeries were all performed under general anesthesia in all patients by
the same surgeon at Assiut Al-Azhar university hospital.
Frontalis Sling Suspension was performed using modified Fox pentagon
technique using silicone rod. Two marks were made in upper lid lateral to
temporal limbus and medial to nasal limbus 2 mm above lash line. Next two
marks were made just medial and lateral to lid incision above superior brow. A
forehead incision was then marked midway about 1 cm above the brow. The
five incisions were then made using a No.15 blade. The needle of sling
suspension set was then slightly bent and passed from central forehead incision
to lid incision and back to forehead incision in clockwise manner to form a
pentagon. Lid Guard was used to protect the cornea and support the lid. Tie the
ends of the silicone rod with a square knot and adjust the tension to reproduce a
normal eyelid contour.
In case of a bilateral frontalis sling surgery ideal upper lid height post
operatively is ½mm below superior limbus. In unilateral cases, the lid margin
sets at 2 mm above the level of the non ptotic eyelid. The forehead incision was
then closed with 6/0 Vicryl Suture and removed after 5 days. Postoperative
gentamycin eye ointment was used at bed time for a week.

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Postoperative evaluation:
Lid height, contour, Lid crease position, lagophthalmos, corneal exposure
and other complications were assessed in all the patients.
The postoperative eyelid symmetry was calculated as the difference
between MRD of the operated on and fellow eyelid, and was considered
satisfactory if it was 1mm or less. Postoperative cosmetic outcome was graded
from 1 to 3 with 1 score indicative of good results, 2 as fair and 3 as poor.
Follow up:
Postsurgical evaluation was performed at 1 week, 2 weeks, 1 month, 3
months and at 6 months.
RESULTS:
Age ranges from 16 months to 18 years. 28 eyes (71.8%) were of female
patients and 11 eyes (28.2%) were of male patients. The mean preoperative
best corrected visual acuity (BCVA) was 0.033. Amblyopia was found in 12
(30.77%) cases. MRD increased an average of 2.5 ± 0.91 mm, from a mean
preoperative 0.4 ± 0.22 mm with P-value less than 0.05. Postoperative 34
(87.18%) eyes had good correction. 4 (10.26%) eyes had fair correction and 1
(2.56%) eye had poor correction. Lagophthalmos occurred in 9 (23.07%) eyes
at the end of follow up period. Complications encountered were corneal
exposure in 3 eyes, one of them underwent loosening of sling and 2 were
managed by use of topical lubricants and taping at night . One Patient had
recurrence of Ptosis due to slippage of silicone rod over tarsus. No patients had
granuloma formation or infection. 2 patients underwent sling readjustment. The
chin-up head posture was present in 14 cases (35.9%) preoperatively and
diminished to 3 cases (7.7%) postoperatively with P-value less than 0.05 . Lid
crease was present and at a level of ≥ 4 mm in 35 cases (89.74%) after surgery.

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Table 1: Preoperative evaluation.
Range Mean SD
Margin reflex distance -1 (MRD-1) -2 to +1 0.4 mm 1.014
Levator muscle excursion (mm) 0 to 4 1.6 1.008
Table 2: Result evaluation.
No. %
Age (16 months to 18 years) 4.75 years
(mean)
Sex(male/ female) 9 / 21 30 / 70
Amblyopia 12 30.77
Best corrected visual acuity (BCVA): 0.033 (mean)
Postoperative God 34 87.18
correction
Fair 4 10.26

Poor 1 2.56
Complications Lagophthalmos 9 23.07

Corneal complications 3 7.7
Suture granuloma or 0 0
infection
Recurrence 1 2.56
Lid crease Present & level ≥ 4 mm 35 89.74
Preoperative abnormal head position 14 35.9
Postoperative abnormal head position 3 7.7
Table 2: Margin reflex distance 1 Changes over 6 months.
MRD1 (mm) One week 4 weeks 3 month 6 month
Mean 2.9 3.5 3.4 3.3
S.D 0.91 0.84 0.81 0.86
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Mahmoud Abd El-Badie Mohamed
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Female
70%
%
Male
30%

Figure 1: Pie graphic of Sex distribution among patients.

40
35
30
25
20
15
10
Figure 2: Grades of postoperative correction.

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Figure 3: Postoperative lagophthalmos

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Mahmoud Abd El-Badie Mohamed
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Figure 4: Preoperative and postoperative photos of a case of unilateral
severe ptosis

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DISSCUSSION
Severe ptosis may result in abnormal head posture and amblyopia due to
occlusion of visual axis. Therefore, surgical intervention is indicated at an early
age. Until now, silicon frontalis suspension is the first choice of surgery for
(3)
sever ptosis with poor levator muscle function .
Since 1977, repair of ptosis by frontalis muscle and fascia lata were first
(9)
developed by Crawford et al. . Unfortunately, the fascia lata has a more
permanent nature and induces scarring and loss of mobility of the upper eyelid,
unsightly scar in the thigh region, hematoma formation, keloid formation and
herniation of the muscle belly. Also Fascia lata cannot be harvested in children
(10)
below three years of age .
Some ophthalmologists tried to develop a new method of frontalis
suspension to resolve the problem. The technique of correction of ptosis with
(11)
poor levator function were first adopted by Tillet et al in 1966 . They used
silicon band and rod in frontalis suspension correction of ptosis. Silicon rod is
readily available, easily adjustable if there is under or over correction of ptosis,
well tolerated by the surrounding tissues and has good elasticity, which
provides for good lid closure. In addition, silicone frontalis sling requires
small skin incisions and less surgical time.
(12,13)
The silicone material for frontalis sling has been tried successfully .
(14)
Lelli et al (2009) compared the results of silicone rod with preserved fascia
lata for frontalis sling operation in congenital ptosis and found better cosmetic
results and lower recurrence rate with silicon rod.
In our study good correction occurred in 87.18% of eyes.
The incidence of exposure keratopathy following silicon frontalis
(15)
suspension cannot be omitted. Van Sorge et al. had reviewed 101 eyelids
receiving silicon frontalis suspension and their cohort study demonstrated a 26
% risk of exposure keratopathy following operation. In our study, corneal
exposure occurred in 7.7% (3/39) of eyes, one of them underwent loosening of
sling and 2 were managed by use of topical lubricants and taping at night.
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(16)
Ben Simon et al. mentioned the recurrence rate about 26% and Lelli at
(14)
al (2009) found the recurrence of ptosis is almost 10 %.
In our study, One Patient (2.5%) had recurrence of Ptosis due to slippage
of silicone rod over tarsus.
CONCLUSION:
Silicone rod is an effective material in frontalis suspension for the treatment of
severe congenital ptosis with poor levator function. The procedure is easy, fast,
and leads to less tissue trauma.

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