Surgical treatment for medically refractory myasthenic blepharoptosis

Abstract

PurposeCurrently, only a few reports have recommended surgery as a suitable treatment for blepharoptosis associated with myasthenia gravis. The present study aims to introduce our surgical criteria, surgical options, outcomes, and precautions for medically refractory myasthenic blepharoptosis.Patients and methodsEight patients who failed to respond to at least 2 years of medical treatment and who underwent blepharoptosis surgery, from January 2008 to December 2011, were enrolled in this study. Medical records, photographs, and questionnaire results regarding postoperative status were evaluated. Of the eleven procedures performed, four involved frontal suspension, four involved external levator advancement, one involved nonincisional transconjunctival levator advancement, and two involved subbrow blepharoplasty with orbicularis oculi muscle tucking. The margin reflex distance improved postoperatively in seven patients.ResultsSeven patients had very minimal scarring, and one had minimal scarring. Five patients showed no eyelid asymmetry, one had subtle asymmetry, and two had obvious asymmetry. Seven patients were very satisfied, and one patient was satisfied with the overall result. Postoperative complications included mild lid lag with incomplete eyelid closure, prolonged scar redness, and worsened heterophoria. No patient experienced postoperative exposure keratitis or recurrent blepharoptosis during the study period.ConclusionOur results indicate that blepharoptosis surgery is effective for patients with myasthenia gravis, especially those with residual blepharoptosis despite multiple sessions of medical treatments. We recommend that neurologists and surgeons collaborate more systematically and discuss comprehensive treatment plans to increase the quality of life for patients with myasthenia gravis.

More than meets the eye: a comprehensive review of blepharoptosis

“…Ptosis can temporarily improve with edrophonium/pyridostigmine testing (acetylcholinesterase inhibitor) or ice pack testing (slowed enzymatic activity of acetylcholinesterase). Surgical ptosis correction requires meticulous selection of candidates that have experienced medical therapy failure or have been stable on medical therapy for 3-4 years [43] . With external levator advancement, 80%-90% of patients can achieve increased lid height [44,45] .…”

“…Thyroid eye disease can uncommonly present with ptosis and must be managed with corticosteroids and/or immunomodulatory therapy to ensure 6-9 months of stability before eyelid surgery can be considered [85,86] . Given the significant fluctuation of levator function in MG, cholinesterase inhibitors and/or corticosteroids should ideally be titrated to ensure stabilization for 3-4 years prior to surgical correction [43] . While not true ptosis, neuromyotonia of the levator palpebrae superioris has been documented to cause pseudoptosis of the contralateral eye via Hering's law of equal innervation.…”

Controversies in Ocular Myasthenia Gravis

“…Supportive measures as crutch glasses for severe ptosis and prisms in patients with diplopia are helpful in treatmentresistant OMG. Ptosis surgical correction is effective and well-tolerated when exposure keratitis is avoided (90,111); the possibility of diplopia worsening should be discussed beforehand. Topical naphazoline, a mainly α2-agonist, was found to be effective in relieving mild to moderate ptosis (112).…”

A unique subphenotype of myasthenia gravis

“…Although we have performed both lid elevation and ocular realignment surgery on a few cases with treatment‐resistant OP‐MG, the results are similar to other published cohorts, and a few conclusions can be drawn. A Japanese series found that seven of eight patients who underwent lid‐elevation procedures for treatment‐resistant myasthenic ptosis, present for at least 2 years and with minimal circadian changes, were satisfied with the outcome . The Mayo clinic described nine patients who underwent surgery for treatment‐refractory ptosis after trying MG therapies for at least 12 months; half of their cases required additional procedures owing to undercorrection of ptosis, but this is preferable to overcorrection and secondary‐exposure keratitis …”