BACKGROUND: Lagophthalmos, a common complication after blepharoptosis correction, has plagued oculoplastic surgeons. The goal of this study was to investigate the effect of tape eyelid closure on reducing the occurrence of lagophthalmos after blepharoptosis correction.
METHODS: From April 2020 to June 2021, a total of 112 patients with severe congenital ptosis received corrective surgery at the Department of Plastic and Reconstructive Surgery, Xijing Hospital, Fourth Military Medical University. Of these, 48 underwent frontalis muscle advancement technique and 64 underwent conjoint fascial sheath suspension. Preoperative data collected included demographics, levator function, Bell\'s phenomenon, and marginal reflex distance 1 (MRD1). Postoperative data included surgery type, MRD1, eyelid closure function, aesthetic outcomes (including eyelid contour, eyelid symmetry, and eyelid crease), keratitis, and other complications.
RESULTS: Frontalis muscle advancement technique group: the median of safe eye closure time was 7.3 months (positive Bell\'s phenomenon; interquartile range [IQR], 3.8-10.8 months) and 13.9 months (poor Bell\'s phenomenon; IQR, 11.6-16.1 months). There was a significant improvement between the preoperative and postoperative MRD1 (-1.52 ± 0.82 vs 3.85 ± 0.58 mm, P < 0.05). Conjoint fascial sheath suspension group: the median of safe eye closure time was 5.7 months (positive Bell\'s phenomenon; IQR, 2.9-8.5 months) and 12.4 months (poor Bell\'s phenomenon; IQR, 8.1-16.7 months). There was a significant improvement between the preoperative and postoperative MRD1 (-1.02 ± 0.91 vs 4.15 ± 1.03 mm, P < 0.05). All patients/guardians were satisfied with the aesthetic outcomes.
CONCLUSIONS: Tape tarsorrhaphy is a safe, easy-to-learn method for treating lagophthalmos with a good aesthetic outcome.

BACKGROUND: Poor Bell\'s phenomenon is often considered a relative contraindication for ptosis surgery, as it increases the risk of corneal exposure and dry eye symptoms after surgery. However, the Bell\'s phenomenon may vary in different individuals and sleep stages, making it inaccurate to predict the position of the eye during sleep based on awake examination. This study aimed to investigate the role of Bell\'s phenomenon in ptosis surgery and the management of nocturnal lagophthalmos.
METHODS: We conducted a retrospective case series of 23 patients with ptosis and poor Bell\'s phenomenon who underwent different surgical techniques at Xijing Hospital from April 2020 to June 2021. We assessed Bell\'s phenomenon at different stages of sleep and collected data on ptosis degree, surgical approach, lagophthalmos, complications, and outcomes.
RESULTS: Of the total 23 patients originally considered for study, 9 with frontalis muscle advancement technique, 8 with conjoint fascial sheath suspension, 4 with levator resection technique, and 2 with levator aponeurosis plication technique. All patients achieved satisfactory correction of ptosis. One patient had prolonged lagophthalmos and underwent reoperation to lower the eyelid height. Other complications were minor and resolved with conservative treatment.
CONCLUSIONS: We conclude that poor Bell\'s phenomenon is not a relative contraindication for ptosis surgery. Nocturnal lagophthalmos should be monitored after ptosis surgery regardless of the Bell\'s phenomenon results. Tape eyelid closure can be an effective solution to protect the corneal surface during nocturnal lagophthalmos.
METHODS: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

For moderate ptosis associated with fair levator function (LF), the levator resection is the most commonly used procedure. However, the levator resection technique still has some disadvantages, such as residual lagophthalmos (RL), undercorrection, conjunctival prolapse, and eyelid contour abnormality. To solve the above problems, our team have made modifications to the levator resection technique in three aspects: releasing the levator muscle sufficiently, preserving the supporting structure of the conjunctiva, and placing multiple suture sites.
Fifty-seven patients (81 eyes) underwent the modified levator resection technique and were enrolled in the study. Preoperative data collected included age, sex, margin reflex distance 1 (MRD1), and LF. Postoperative data collected included MRD1, RL, patient satisfaction, complications, and length of follow-up.
Mean MRD1 significantly increased from 1.45 ± 0.65 mm preoperatively to 3.57 ± 0.51 mm postoperatively. Mean LF significantly increased from 6.49 ± 1.12 mm preoperatively to 9.48 ± 1.39 mm postoperatively. Successful correction was obtained in 77 eyes (95.1%). Mean RL was 1.09 ± 0.57 and 72 eyes (88.9%) showed excellent or good eyelid closure function. Fifty-four patients (94.7%) were completely satisfied with the final result. Complications such as hematoma, infection, conjunctival prolapse, suture exposure, corneal abrasion, and keratitis were not found in any cases during follow-up.
This modified levator resection technique introduced in this study is effective in correcting moderate congenital blepharoptosis, while minimizing RL, undercorrection, conjunctival prolapse, eyelid contour abnormality by releasing the levator muscle sufficiently, preserving the supporting structure of the conjunctiva, and placing multiple suture sites.
This journal requires that authors 42 assign a level of evidence to each article. For a full 43 description of these Evidence-Based Medicine ratings, 44 please refer to the Table of Contents or the online 45 Instructions to Authors www.springer.com/00266 .

OBJECTIVE: To investigate the association of meibomian gland dysfunction (MGD) and ocular surface exposure with tear film instability in untreated thyroid eye disease (TED) patients.
METHODS: A cross-sectional study of TED patients from September 2020 to September 2022 was conducted. Ocular surface parameters included ocular surface disease index (OSDI), tear meniscus height (TMH), non-invasive tear break-up time (NITBUT), partial blinking rate, lipid layer thickness (LLT), meibomian gland dropout (meiboscore), Schirmer\'s test, and corneal punctate epithelial erosions (PEE). Ocular surface exposure was assessed by the margin reflex distances of the upper and lower eyelid (MRD1 and MRD2), the amount of exophthalmos, lateral flare, and lagophthalmos.
RESULTS: In total, 152 eyes from 76 TED patients (64 females and 12 males, age 42.99 ± 12.28 years) and 93 eyes from 61 healthy controls (51 females and 10 males, age 43.52 ± 17.93 years) were examined. Compared with control eyes, TED eyes had higher OSDI, TMH, LLT, and PEE; shorter NITBUT; and worse meiboscore (all p < 0.05). They also had larger amounts of exophthalmos, longer MRD1, more lateral flare, and lagophthalmos. Multivariate analysis identified an association of the tear film instability with lagophthalmos (β = -1.13, 95%CI: -2.08, -0.18) and severe MGD in the lower eyelid (β = -5.01, 95%CI = -7.59, -2.43).
CONCLUSIONS: Dry eye in TED is mainly manifested as evaporative dry eye disease. Severe lower eyelid MGD and worse lagophthalmos were significantly associated with tear film instability in treatment-naive TED patients.

Several types of surgeries have been used in the treatment of congenital ptosis, but the optimal methods and materials for this treatment are unknown.
The study aims to evaluate the comparative effectiveness and safety of various surgical methods and materials for treatment of congenital ptosis.
We performed comprehensive searches of five databases, two clinical trial registries and one gray literature database from inception to January 2022 for related trials to include in this study. Meta-analysis was performed to evaluate the effect of surgical methods and materials on the primary outcomes: margin reflex distance 1 (MRD1), palpebral fissure height (PFH), and degree of lagophthalmos; and secondary outcomes: undercorrection, entropion, corneal epithelial defects, wound dehiscence, recurrence, infection, and cosmetic outcomes.
A total of 14 trials evaluating 909 eyes of 657 patients were included in our study. Compared with the levator plication, the frontalis sling significantly increased the MRD1 (MD = - 1.21; 95% CI [- 1.69, - 0.73]), and the levator resection significantly increased the PFH (MD = 1.30; 95% CI [0.27, 2.33]). For the frontalis sling surgical patterns, the fox pentagon was significantly better than the double triangle at improving the degree of lagophthalmos (MD = 0.70; 95% CI [0.32, 1.08]), while the opened pattern provided statistically better cosmetic outcome than the closed frontalis sling. Analysis of surgical material showed that absorbable sutures significantly increased the MRD1 (MD = 1.16; 95% CI [0.60, 1.72]) compared to non-absorbable sutures when used in levator plication; frontalis sling surgeries performed with silicon rods significantly increased the PFH (MD = 0.88; 95% CI [0.29, 1.47]) compared to those performed with Gore-Tex strips, while autogenous fascia lata provided statistically better aesthetic outcome for lid height symmetry and contour.
Different surgical methods and materials appear to affect different aspects of the congenital ptosis treatment outcome.
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

OBJECTIVE: To elucidate the clinical implications of corneal striae (CS) in thyroid associated orbitopathy (TAO) patients.
METHODS: In this cross-sectional study, the presence of CS was confirmed after topical fluorescein staining on a slit lamp for consecutive treatment-naive TAO patients. Orbital parameters, including margin reflex distances, lagophthalmos, exophthalmos, intraocular pressure and radiological measurements, were compared between eyes with and without CS. The largest cross-sectional areas of each rectus muscle were measured by segmenting the T1-weighted (T1W) magnetic resonance images (MRI). The logistic regression analyses were used to evaluate the associations between CS and orbital parameters and rectus muscle measurements.
RESULTS: Fifty-three consecutive TAO patients (presenting age 46.47 ± 14.73 years, clinical activity score 1.77 ± 1.25) who had unilateral CS were enrolled. In univariate analysis, both the degree of lagophthalmos and the area of the levator palpebrae superioris-superior rectus complex (LPS/SR) on T1W MRI were significantly larger in CS eyes compared to eyes without CS (p < 0.05). Multivariate analyses showed that CS in TAO patients were significantly associated with the degree of lagophthalmos (OR = 1.75, 95% CI: 1.18-2.61, p < 0.05) and LPS/SR area (OR = 19.27, 95% CI: 1.43-259.32, p < 0.05) but not with the other parameters. CS could predict LPS/SR enlargement and larger lagophthalmos in TAO (p < 0.05). The largest cross-sectional areas of LPS/SR and inferior rectus were positively correlated with clinical activity scores (p < 0.05).
CONCLUSIONS: The presence of CS in TAO eye is significantly associated with LPS/SR enlargement and worse lagophthalmos. CS might be evaluated further as a potential ocular surface biomarker to identify upper lid and LPS/SR involvement in TAO.

BACKGROUND: Lagophthalmos and lid lag is the most common complication after ptosis correction. Great efforts had been made to control it, but little was known about the factors influencing it. So we ran this research to explore the possible mechanisms underlying it. This would be beneficial to solving this problem.
METHODS: In this cohort study, patients treated with the forked frontalis muscle aponeurosis suspension and levator aponeurosis-Muller\'s muscle complex resection were identified. Lagophthalmos height and lid lag was measured at the postoperative week 1 visits. The Spearman correlation test was run to test whether lagophthalmos was related to patients\' age, levator function, and severity of ptosis. Then we measured the contents of collagen and elastin fibers of frontalis muscle fascia and levator aponeurosis from the patients and levator aponeurosis from cadaver heads histologically and compared the contents in these 3 groups.
RESULTS: No correlation was found between patients\' age, levator function, the severity of ptosis, and with lagophthalmos height. However, the contents of collagen and elastic fibers were both higher in the frontalis fascia than in the normal aponeurosis tissues. The difference in collagen fibers content between frontalis muscle fascia and patients\' aponeurosis was statistically insignificant.
CONCLUSIONS: The severe lagophthalmos and lid lag may be caused by the poor mechanical features of the frontalis muscle. A better source of motive force to elevate the eyelids and a novel sling material with proper elasticity and stiffness would be the solution to improve the lagophthalmos and lid lag after ptosis correction.