This retrospective cohort study included a group of consecutive patients diagnosed with blepharochalasis from January 2009 to December 2019 in Beijing Tongren Eye Center. The Medical Ethics Committee of the Beijing Tongren Hospital approved the study protocol, and followed the principles of the declaration of Helsinki.
All participants with blepharochalasis symptoms (including recurrent idiopathic edema and redness in the eyelid or adnexal tissue of the orbit, and other secondary performances such as thinned and wrinkled eyelids, ptosis, lacrimal gland prolapse, lids retraction, horizontally shortened palpebral fissure or rounded deformity of the lateral canthal angle) and underwent orbital plastic surgery were included. Patients were excluded if they had undergone previous anterior or posterior ocular surgery, had systematic or ocular diseases (such as heredity angioedema or Ascher’s syndrome, Thyroid-related ophthalmopathy, floppy eyelid syndrome, orbital cellulitis, sarcoidosis, idiopathic orbital inflammation, hereditary angioedema, dacryoadenitis, lacrimal gland tumor, localized cutis laxa, or any other known ocular diseases), or refuse to undergo the orbital plastic surgery.
After obtaining the informed consent of the patients or their guardians, all participants underwent an interview by a trained ophthalmologist with standardized questionnaire about the complaint, symptoms, age of first onset, the characteristics of acute attacks(frequency, duration of each acute attack, the interval between the two attacks), triggering factors, family history and also the history of allergies, trauma, and other diseases during their first visit. Age of the onset of puberty was also questioned (the development of secondary sexual characteristics,in females, such as breast and hip growth, and menstruation;In males, testicular development, growth of facial hair, and changes in voice[7]). All participants underwent detailed clinical examinations. The information of the best-corrected visual acuity, eyelid appearance, contour, position, color, deformity of medial or lateral canthal angles, and also the function of levator muscle was recorded[8, 9]. Associated manifestations including ptosis, lacrimal gland prolapse, horizontally shortened palpebral fissure or rounded lateral canthal angle were also recorded.
After enrollment in our study, all the patients with active blepharochalasis were followed up every six months, without any medical treatment. Active blepharochalasis was defined as recurrent episodes of painless and non-erythematous edema of the eyelids in association with telangiectasia[6]. Surgery would be scheduled after at least 2-year quiescent period with no recurrent attack and exacerbation of lesions, and followed up for at least 1 year after surgery. All surgical interventions were performed by the same experienced surgeon (Dongmei Li, MD) under local anesthesia. Surgical approaches varied according to the clinical manifestations of each individual, such as blepharoplasty for wrinkled and redundant eyelids, levator aponeurosis advancement for ptosis, prolapsed lacrimal gland resuspension, canthoplasty for lateral and medial canthal angle deformity. Other surgical approaches were combined according to whether other manifestations were complicated. The most common surgical procedures of each manifestation were performed as follows:
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Blepharoplasty: all those eyes underwent blepharoplasty, cutting the eyelid skin along the along the lid-crease line, resecting the redundant eyelid lid skin and recreating of the eyelid crease.
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Levator aponeurosis advancement: for eyes with ptosis, cutting off the inner and outer corners of the levator muscle, and also the ligament was considered important (Figure A).
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Prolapsed lacrimal gland reposition: the prolapsed gland was suture repositioned to the orbital periosteum of the lacrimal fossa (Figure B, C). The orbital septum was sutured (Figure D), and then the redundant lid skin was removed[10].
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Canthoplasty: the lateral canthal deformity was managed by orbital periosteal flap translocation to correct the rounded lateral canthal angle. The "Y" shaped incision was applied (Figure E). The tarsus was stretched temporally to the new point to determine the length of the orbital periosteal flap (Figure F), and was sutured to the appropriate part of the tarsus (Figure G). As for the media canthal deformity,a cross self-drilling tapping titanium nail was used to reattach the media canthal deformity.
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Lower eyelid retraction correction: along the lower eyelid skin incision, Medpore lower lid spacer was used to correct the lower eyelid retraction.
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Punctum reposition: for those eyes combined with punctum outside deformity, surgery for punctum repositioning was performed.
Statistical analysis was performed using a commercially available statistical software package (SPSS for Windows, version 20.0, IBM-SPSS, Chicago, IL). In a first step, we determined the mean values (presented as mean ± standard deviation) and median values of the main outcome parameters. In a second step, we performed independent T test analyses to evaluate the significance of age between unilateral and bilateral patients. The Chi square test was used to assess association between males and females. A P-value < 0.05 was considered to indicate statistical significance.