Keywords
blepharoptosis - elderly patients - superficial punctate keratopathy - margin reflex
distance-1 - subjective symptoms
Introduction
Blepharoptosis (BP) surgery is commonly performed in both young and elderly patients
with the goal of broadening the visual fields.[1]
[2]
[3]
[4]
[5]
[6] The majority of BP surgery is performed for dehiscence or stretching of the aponeurosis
to the tarsus. It is achieved by nondelivery of contractile power to the upper eyelid,
which requires resection of redundant skin and/or shortening of the levator aponeurosis.[7]
[8] However, when evaluating the surgical outcomes, most clinical surgeons that perform
BP tend to focus on cosmetic improvements, such as upper-eyelid contour and left-right
difference in the pretarsal show.[5]
[9]
[10]
BP surgery widens the visual field and cosmetic improvement can be obtained, but not
all patients are satisfied postoperatively. Elderly patients can have functional problems
after BP surgery that differ from younger patients, such as visual disturbance and
dry eye symptoms.[11]
[12] Wider discussion of BP surgery is therefore needed, as various subjective symptoms
in elderly patients require improvement.
Elderly patients are known to often have complications from BP surgery that can result
in the appearance or exacerbation of superficial punctate keratopathy (SPK); however,
there are no reported cases of pre- and postoperative changes in SPK status. This
study, therefore, aims to investigate the safety and efficacy of BP surgery in elderly
patients using subjective symptoms and measurement of SPK scale classification.
Methods
Included in the study were the 22 patients (44 eyes) with bilateral BP surgery that
underwent surgery at our hospital between April 2019 and February 2020. Patients comprised
8 males and 14 females with a mean (±standard deviation) age of 75.7 ± 8.2 years (range:
61–89). Exclusion criteria were inability to answer the questionnaires and the inability
to attend the 3-month follow-up visit. We also excluded patients with congenital,
neurogenic, myogenic, and traumatic ptosis and those with history of glaucoma. Patients
with neurogenic or myogenic ptosis were ruled out after consultation with members
of our department of neurology. Informed consent was obtained from each patient before
the start of the study. This study was approved by an appropriate institutional review
board (approval number 2549), and performed in accordance with the tenets of the Declaration
of Helsinki.
BP surgery always consisted of transcutaneous levator advancement, and blepharoplasty
including resection of soft tissue (skin, subcutaneous tissue, and the orbicularis
oculi muscle).[1]
[13]
[14]
[15] Intraoperative quantification in cases of transcutaneous levator advancement was
conducted so that margin reflex distance-1 (MRD-1) was more than or equal to 4.0 mm
while in the supine position. MRD-1 measurement, a questionnaire survey of symptoms,
SPK grading, and BUT (tear breakup time test) value were taken pre- and 3 months postoperatively
for evaluation.
Margin Reflex Distance-1 Measurement
The upper eyelid height before and after surgery was assessed in primary position
using MRD-1 value, defined as the distance between the central pupil reflex and the
upper eyelid margin.[16]
The degree of disability was scored on a Likert scale ranging from 1 to 5, with lower
numbers indicating a greater burden. Patients answered a 10-item questionnaire on
eye symptoms including poor visibility, ocular fatigue, heavy eyelids, painful or
sore eyes, dry sensation in the eyes, foreign body sensation, and difficulty in focusing
and double vision, and it included accompanying symptoms, such as headaches and stiff
shoulders.
The presence of any corneal staining was documented as follows: after administration
of fluorescein in the inferior fornix using a paper fluorescein strip (FLUORES Ocular
Examination Test Paper 0.7 mg; Ayumi Pharmaceutical, Tokyo, Japan), the corneal epithelium
and BUT were examined using a slit-lamp (RO-5000; Rodenstock, Munich, Germany). SPK
was graded using the area and density of the lesion as parameters. Area and density
were evaluated on a 4-point scale according to the method used by Miyata et al (0:
none, 1: mild, 2: moderate, 3: severe).[17] After fluorescein staining, the total sum of the area of SPK was graded as A0 when
there was no punctate staining, A1 when the area occupied less than one-third of the
cornea, A2 when the area occupied between one- and two-thirds of the cornea, and A3
when the area occupied more than two-thirds of the cornea. The density was graded
as D0 when there was no punctate staining, D1 when the density was sparse, D2 when
the density was moderate, and D3 when the density was high or the lesions overlapped
([Fig. 1]).[17] We collaborated with an ophthalmologist regarding measurements and examinations.
Since these assessments involve a subjective component, the co-authors, a plastic
surgeon (K.U) and an ophthalmologist (H.I), carefully considered each case when determining
the SPK scale.
Fig. 1 Superficial punctate keratopathy and density scale classification. Area and density
were evaluated on a 4-point scale (none: 0, 1: mild, 2: moderate, 3: severe).
Statistical Analysis
Continuous variables were analyzed using the Mann–Whitney U test and Wilcoxon signed-rank
sum test. A receiver operating characteristic curve was created, and the area under
the curve was calculated. A p-value less than 0.05 was considered statistically significant. All statistical analyses
were done using JMP 14 software (SAS Institute Inc., Cary, NC).
Results
-
Change of MRD-1: the median (interquartile range) MRD-1 was 1 mm (0.125–1.5) preoperatively and 2.5 mm[2]
[3] postoperatively, representing a significant postoperative improvement (p < 0.05, Wilcoxon signed-rank test) in [Fig. 2].
-
Evaluation by questionnaire survey: all 10 items on the questionnaire tended to have increased scores after surgery,
and significant differences were observed in 7 items (poor visibility, ocular fatigue,
heavy eyelid, foreign body sensation, difficulty in focusing, headaches, and stiff
shoulders ([Table 1]).
-
Change of SPK scale: the mean SPK area was 0.25 ± 0.44 preoperatively and 0.39 ± 0.58 postoperatively.
The mean SPK density was 0.3 2 ± 0.6 preoperatively and 0.5 ± 0.76 postoperatively,
representing a significant postoperative increase (p < 0.05, Wilcoxon signed-rank test) in [Table 2].
-
Cut-off of MRD-1 amount of change graded by SPK: ΔMRD-1 equal to 2.5 mm was the cutoff point to separate the SPK improvement/unchanged
group from the deterioration group, and its area under the curve was 0.6605 ([Fig. 3]).
-
Degree of exacerbation of SPK based on change in MRD-1: SPK area and density significantly deteriorated in the group with more than or equal
to ΔMRD 2.5 mm ([Table 3]).
-
Representative cases: case 1 was a 75-year-old Japanese woman. The preoperative MRD-1 was 1 mm, and the
postoperative MRD-1 increased to 3.0 mm, an increase of 2.0 mm. SPK was not observed
either preoperatively or postoperatively ([Fig. 4A–D]).
Case 2 was a 73-year-old Japanese woman. The preoperative MRD-1 was 1 mm, and the
postoperative MRD-1 increased to 3.5 mm, an increase of 2.5 mm. SPK was not observed
preoperatively, but showed mild areas and density of SPK (A1D1) postoperatively ([Fig. 5A–D]).
Fig. 2 Pre- and postoperative margin reflex distance-1 (MRD-1). The median MRD-1 was 1 mm
(interquartile range: 0.125–1.5) preoperatively and 2.5 mm (interquartile range: 2–3)
at 3 months postoperatively. Boxes indicate medians; error bars, upper and lower limits.
Table 1
All ten items on the questionnaire tended to have increased scores after surgery,
and significant differences were observed in seven items
|
Symptoms
|
Pre
|
Post
|
|
Poor visibility
|
2 (1–4)
|
5[a] (4–5)
|
|
Ocular fatigue
|
2 (2–3)
|
4[a] (3–4)
|
|
Heavy eyelid
|
2 (1–3)
|
4[a] (3–5)
|
|
Painful or sore eyes
|
4 (4–5)
|
5 (3–5)
|
|
Dry sensation in eyes
|
3.5 (2–4)
|
4 (3–5)
|
|
Foreign body sensation
|
3 (2–4)
|
4[a] (3–5)
|
|
Hard to focus
|
4 (2–5)
|
5[a] (4–5)
|
|
Double vision
|
4 (3–5)
|
5 (4–5)
|
|
Headaches
|
4 (3–5)
|
5[a] (4–5)
|
|
Stiff shoulders
|
3 (2–4)
|
4[a] (3–5)
|
Abbreviations: Pre, preoperative; Post, postoperative at 3 months.
a
p < 0.05.
Table 2
The mean SPK area was 0.25 ± 0.44 preoperatively and 0.39 ± 0.58 postoperatively.
The mean SPK density was 0.3 2 ± 0.6 preoperatively and 0.5 ± 0.76 postoperatively,
representing a significant postoperative increase
|
Pre
|
Post
|
p-Value
|
|
SPK area
|
0.25 ± 0.44
|
0.39 ± 0.58
|
0.0832
|
|
SPK density
|
0.32 ± 0.6
|
0.5 ± 0.76
|
0.0308
|
Abbreviations: Pre, preoperative; Post, postoperative at 3 months; SPK, superficial
punctate keratopathy.
A comparison of the pre- and postoperative parameters. Values are presented as mean ± standard
deviation. p-Value determined Wilcoxon signed-rank test.
Fig. 3 Receiver operating characteristic curve for the support tool to detect margin reflex
distance-1 (MRD-1) with blepharoptosis surgery. ΔMRD-1 equal to 2.5 mm was the cutoff
point to determine whether superficial punctate keratopathy improve or unchanged group
from the deterioration group, and its area under the curve was 0.6605.
Fig. 4 Case 1 was a 75-year-old Japanese woman. The preoperative margin reflex distance-1
(MRD-1) was 1 mm, and the postoperative MRD-1 increased to 3.0 mm, an increase of
2.0 mm (A, B). Superficial punctate keratopathy (SPK) was not observed either preoperatively or
postoperatively (C, D). Case 2 was a 73-year-old Japanese woman. The preoperative MRD-1 was 1 mm, and the
postoperative MRD-1 increased to 3.5 mm, an increase of 2.5 mm (A, B). SPK was not observed preoperatively, but showed mild areas and density of SPK (A1D1)
postoperatively (C, D).
Table 3
SPK area and density significantly deteriorated in the group with ≥ ∆MRD 2.5 mm
|
ΔMRD-1
|
≥2.5 mm
|
≤ 2.0 mm
|
p-Value
|
|
ΔSPK area
|
0.38 (0.5)
|
0 (0.47)
|
0.0196
|
|
ΔSPK density
|
0.43 (0.51)
|
0.04 (0.51)
|
0.0183
|
Abbreviations: MRD-1, margin reflex distance-1; SPK, superficial punctate keratopathy.
The amount of change in SPK A and D was examined by dividing into groups with changes
in MRD-1 of 2.5 mm or more and less than 2.5 mm.
Fig. 5 Case 2 was a 73-year-old Japanese woman. The preoperative MRD-1 was 1 mm, and the
postoperative MRD-1 increased to 3.5 mm, an increase of 2.5 mm ( A, B). SPK was not observed preoperatively, but showed mild areas and density of SPK (A1D1)
postoperatively (C, D).
Discussion
SPK is a petechial and multiple corneal epithelial defect.[18] It may indicate conditions that are more severe than SPK, such as corneal erosion
and persistent epithelial defect. As SPK worsens, symptoms and discomfort related
to the eyes are more likely to appear.[19] To our knowledge, this is the first study to report the pre- and postoperative changes
in SPK in patients with BP in detail. SPK is known to mainly occur below the cornea
after BP surgery. Asamura et al[6] reported that postoperative MRD-1 should be less than 3 mm because of the possible
appearance of SPK due to BP surgery. In this study, SPK area and density scores were
found to increase when the MRD-1 increase was more than 2.5 mm with surgery. In other
words, BP surgery was found to be a safe and effective way to keep the increase in
MRD-1 within 2.0 mm, especially in elderly patients.
Some surgeons tend to believe that the more MRD-1 increases, the greater the expansion
of the field of vision and the more satisfied the patient will be with the surgery.
The upper eyelid opens and closes along the curvature of the eyeball, and the eyelid
moves flexibly. Surgeons sometimes detect a loss of this flexibility after BP surgery,
and the dry eye symptoms can be exacerbated due to decreased stability of the tear
film and increased friction forces that exist during blinking. The condition for SPK
worsens, resulting in patient complaints.[3]
[6]
[20]
[21] BP surgery in elderly people must therefore be considered to be a very delicate
procedure. There have been no previous reports of a scale evaluation method for SPK
by surgery. SPK scale classification is based on area and density. A scale evaluation
method for SPK reported by Miyata et al[17] was used in this study, and the area and density of SPK were evaluated in the groups
with postoperative MRD-1 of more than 2.5 mm or less than 2 mm ([Table 3]). Increase in MRD-1 more than 2.5 mm is suggested to be associated with the risk
of worsening condition for SPK ([Fig. 3] and [Table 3]).
According to Japanese guidelines, the surgical indication for BP is MRD-1 less than
or equal to 2 mm. When the MRD value is 2 mm, the upper field of view corresponds
to 35 degrees, 1 mm corresponds to 30 degrees, and 0 mm corresponds to 20 degrees.
The upper field of view required in daily life is set to 30 degrees, and related inconvenience
tends to begin to be reported when MRD-1 value is around 1 mm.[10]
[22] Guillon et al[23] also reported that the pupils become smaller as an individual gets older, but stated
that the diameter of the pupils at 55 years and older is approximately 3.5 mm. According
to Telek et al,[24] the pupils become smaller as an individual gets older, and the diameter of the pupils
at 60 years and older is approximately 3 mm. Elsewhere, Murchison et al[25] reported the average MRD-1 in a cohort of Caucasian individuals with an average
age as 2.7 mm. Additionally, the function of the meibomian glands begins to decline
around age 50, and approximately 70% of Japanese over age 60 develop dry eye symptoms.[26]
[27] Based on these reports, a position where the upper eyelid margin does not interfere
with the pupil, as in the patients in this study, a postoperative MRD-1 of around
2.5 mm seems appropriate for BP surgery in elderly patients. The primary surgical
purpose of BP surgery is to widen the visual field by upward displacement of the upper
eyelid margin ([Fig. 1]).
Unlike other fields of medicine that use morbidity and mortality rates as the basis
for evaluation, improvement in various eye-related symptoms, such as those seen in
these cases, is an important factor in the field of plastic surgery. Previous reports
concluded that BP surgery provides significant improvement in vision, peripheral vision,
and quality-of-life activities.[9]
[28] In this survey, there was significant improvement in many symptoms: poor visibility,
ocular fatigue, heavy eyelid, foreign body sensation, difficulty in focusing, and
also accompanying symptoms of headaches and stiff shoulders, concomitant symptoms
of conditions requiring BP surgery.[9]
[28] In other words, BP surgery has resulted in marked improvement in many aspects of
patients' subjective dry eye symptoms and health-related quality of life.
This evaluation method for SPK should also be helpful in various situations, such
as when performing evaluation of the ocular surface for various types of oculoplastic
surgery (e.g., entropion), when describing the time course of changes in SPK area
and density. A major limitation of this study is that it only evaluated those who
received postoperative SPK at 3 months, although it is possible that they may improve
after 1 year.[29]
[30]
[31] BP surgery in elderly people is expected to continue to increase in the current
hyper-aged society. Despite the benefits, surgeons must nonetheless be aware that
BP surgery is a delicate procedure, especially in elderly people and is found to be
a safe and effective way to maintain the increase in MRD-1 within 2.0 mm.
