Clinical value of phenylephrine testing in the upper and lower eyelids of patients with aponeurotic and congenital eyelid ptosis

INTRODUCTION

Eyelid ptosis, which is an abnormal function of the levator palpebra superioris muscle or Müller’s tarsal muscle, is one of the common eyelid disorders seen in oculoplastic surgery. The etiology of ptosis can be congenital,myogenic, neurogenic, and aponeurotic

. Ophthalmic plastic surgeons evaluate levator function (LF) and response to topical phenylephrine for the preoperative evaluation and determination of the appropriate surgical method for ptosis repair, but there is an underestimated situation; upper eyelid ptosis can change the lower eyelid position in both congenital and aponeurotic subgroups of ptosis to maintain the horizontal visual axis without inclination of the head in the primary gaze position

. The possible mechanism of this harmony is a compensatory contraction of the superior rectus/levator complex and simultaneous lower eyelid retractor, thereby displacing the globe upward in the orbit and retracting the lower eyelid with a dynamic lower scleral show

. Few previous studies have highlighted this issue and have shown that lower scleral show improves after ptosis surgery

. The need for a detailed evaluation of the lower eyelid for more precise and successful ptosis surgery prompted us to design this study.

The levator palpebra superioris, the major upper eyelid elevator muscle, contains striated muscle fibers and acts together with Müller’s muscle

. Müller’s muscle and the lower eyelid tarsal muscle are sympathetically stimulated smooth muscles that contract and widen the interpalpebral fissure in the presence of a topical adrenergic such as phenylephrine, a direct alpha-1 adrenergic agonist

. The response to topical phenylephrine is predictive of the outcome of a Müller’s ptosis repair

.Although interpalpebral fissure height is dependent on the lower eyelid position, changes in the lower eyelid position with phenylephrine are not usually measured before surgery

.Eyelid position is frequently described using the marginal reflex distance (MRD) alone for the upper eyelids

.

This study aimed to determine the time in which the maximal response of upper and lower eyelids to phenylephrine testing occurred, the correlation between the upper and lower eyelids,and to compare the test results of different groups of ptosis etiology and severity at different time points.

SUBJECTS AND METHODS

This study was approved by the Institutional Ethics Committee of Bahcesehir University (Date 4.9.2019,No. 2019-12/05), and conducted in compliance with the latest version of the Declaration of Helsinki. Informed consent was obtained from all of the patients.

This was a retrospective analysis of 140 eyes of 87 patients with upper eyelid ptosis who were referred to our clinic between September 2018 and May 2019.Our study included eyes with aponeurotic and congenital upper eyelid ptosis with good LF (＞8 mm). The exclusion criteria were eyelid pathologies such as lower eyelid laxity, a history of previous eyelid surgery or trauma (traumatic ptosis), tumors causing mechanical ptosis or any other known eyelid disease;neurotoxin application 5mo before the phenylephrine testing;systemic or neurologic diseases that might affect eyelid position(such as Parkinson’s disease, Horner syndrome, stroke, cranial nerve palsy, thyroid eye disease, myasthenia gravis).

Baseline ophthalmologic examinations for ptosis included:measurements of Snellen visual acuity, MRD1 defined as the distance from the light reflex to the upper lid margin and MRD2 as the distance to the lower lid margin, LF, scleral show height, and slit-lamp anterior and posterior segment examinations. Eyes with aponeurotic ptosis were divided into four subgroups: age-related, post-operative, contact lens (CL)-induced, and idiopathic etiology.

MRD1 is the distance between the inferior margin of the upper eyelid and the pupillary light reflex in the primary position of gaze. The normal range of MRD1 is 4-4.5 mm. It is measured using a millimeter ruler held adjacent to the patient’s lateral canthus while the patient is in the sitting position, looking at a light source (a penlight) placed 50 cm away from the margin of the upper eyelid. A finger is placed over the patient’s brow to ensure frontalis relaxation

. Ptosis was defined as mild if the MRD1 was ＞1.5 mm, moderate if it was 0.5-1.5 mm, and severe if it was ＜0.5 mm. MRD1 has a negative value if the upper lid margin obstructs the corneal reflex. This value is based on the elevation of the ptotic eyelid until the light reflex appears

.

賴爾，本名周麗，作家，曾獲中國“五個一工程獎”貢獻獎，因其作品長篇魔幻小說《魔法城》而被意少小讀者熟知。生活中的她，時而是縱橫游戲世界大殺四方的女漢子，時而是獨自行走領略各國風情的游者，時而又是咖啡館里安靜讀書的文藝淑女……自由灑脫和沉穩睿智這兩種特質在她身上得以完美融合。

The evaluation of the mean values of MRD1,ΔMRD1, MRD2, ΔMRD2, and scleral show height, with respect to the etiology of ptosis, showed that regardless of the etiology, an increase was observed in all parameters at all measurement times after phenylephrine testing (

＜0.05;Table 3). The ΔMRD1 was highest in eyes with CL-induced ptosis and lowest in eyes with congenital ptosis at the 5

and 15

minutes (

＜0.005; Table 3). On the other hand, scleral show height was highest in eyes with idiopathic ptosis, and lowest in those with senile ptosis at the 5

and 15

minutes(

=0.015; Table 3).

當前國內質量控制工具的利用尚不成熟,仍處于學習階段。而在美國的筆譯項目中,術語管理貫穿整個項目,質量控制更是一個動態過程,并緊密結合各類計算機軟件技術。

Patients’demographics, side of ptotic eye, etiology of ptosis, and concomitant systemic and ocular diseases were recorded.MRD1, MRD2, and scleral show height were measured at baseline, and the 2

, 5

, and 15

minutes of the phenylephrine testing, and recorded by the same author (Gedar Totuk OM).All measurements are given in units of 0.5 mm.

另外，本文控制了其他影響創新的主要因素［3］，包括制度 （INS）、人力資本研究與開發（HKRD）、基礎設施 （INFR）、市場成熟度 （MS）和商業成熟度 （BS）5個因素。此外，考慮到時間和空間的影響，本文還控制了年份和地域的影響。

總之，“共享經濟”實質上是以盈利為目的的共享，它是人們既擔任“消費者”又充當“擁有者”，它把使用權和所有權分離，并實現二者的相互轉化，贏得更高的規模效益。它通過對消費者需求的分析進行資源配置和需求匹配，以最高的精度滿足客戶的需求，同時發揮資源自身的價值。“共享經濟”平臺的運行是一個取代了傳統中介機構，基于自身龐大的供給資源和需求客戶實現再中介化的過程，它持續健康發展的成本收益性也是它利潤的最主要來源。“共享經濟”的運行機制為我國加快轉變經濟發展方式提供了新的方向和動力。

The mean age of the patients was 52.29±16.45 (range, 16-80)y.Twenty-two (25.3%) of the patients were male and 65 (74.7%)were female. The eyelid ptosis was unilateral in 34 (39.1%)patients and bilateral in 53 (60.9%) patients. The ptosis duration (years) was recorded as 7.19±11.47 (range 0.08-45)y.According to the etiology, 124 eyes (88.6%) had aponeurotic and 16 eyes (11.4%) had congenital ptosis. The most common aponeurotic ptosis subgroup was senile ptosis (72%). The severity of ptosis was mild or moderate in 114 eyes (81.4%;Table 1).

翻譯活動要以社會主義核心價值觀為導向，加強思想引領，保證意識形態領域的正確價值取向；