Journal of Ophthalmic Plastic and Reconstructive Surgery

Serum Vitamin D Deficiency Is an Independent Risk Factor for Thyroid Eye Disease
Heisel, Curtis J.; Riddering, Alixandra L.; Andrews, Christopher A.; More
Ophthalmic Plastic and Reconstructive Surgery. 36(1):17-20, January/February 2020.
Purpose:
Thyroid eye disease (TED) is an inflammatory orbitopathy with significant impact on visual function and quality of life. Although studies have shown that patients who are deficient in vitamin D are more likely to develop autoimmune conditions, there are no studies demonstrating a definitive correlation between serum 25-hydroxyvitamin D (25(OH)D) deficiency and an increased risk of TED.
Methods:
This retrospective case–control study compared serum 25(OH)D levels among 4 groups: 1) Graves disease (GD) patients with TED (n = 89); 2) GD patients without TED (n = 89); and healthy control patients matched to 3) the TED group (n = 356); and 4) the GD group (n = 356). The authors compared 25(OH)D level in the TED group measured within 1 year of TED diagnosis to the most recently measured 25(OH)D level in the GD group using Student t test of the log transformation of serum levels. Linear regression was used to control for other risk factors. Thyroid eye disease patients and GD patients were compared separately to their matched healthy control patients with linear mixed models.
Results:
Thyroid eye disease patients displayed significantly lower serum 25(OH)D levels than GD patients (24.8 ± ۱۳.۲ ng/ml vs. 29.4 ± ۱۳.۳ ng/ml; p = 0.006). Controlling for smoking status and previous radioactive iodine treatment did not affect this statistically significant difference.
Conclusions:
Low serum vitamin D is associated with TED diagnosis. Assessing and supplementing vitamin D levels may be an important addition to the early management of GD patients. Future research should include longitudinal studies and prospective clinical trials to further explore the mechanism responsible for the observed association.
Thyroid eye disease is an inflammatory orbitopathy associated with Graves disease. Vitamin D is a known immune system regulator. The authors show that vitamin D deficiency is associated with the development of thyroid eye disease.

Assessment of the Safety and Efficacy of Prolapsed Orbital Fat Resection During Involutional Entropion Repair
Prendes, Mark A.; Geng, June; Ediriwickrema, Lilangi S.; More
Ophthalmic Plastic and Reconstructive Surgery. 36(1):34-37, January/February 2020.
Purpose:
To assess the recurrence rate of involutional entropion in patients treated with a combined approach including a modified Bick procedure, excision of preseptal orbicularis muscle, and conservative resection of prolapsed orbital fat.
Methods:
A retrospective chart review of patients undergoing repair of involutional entropion with the combined procedure including orbital fat resection and a second group with standard entropion repair without orbital fat resection was performed. Only patients with follow-up greater than 6 months were included in the study.
Results:
Seventy eyelids of 54 patients met all inclusion criteria for the combined procedure group over a 9-year period from 2008 to 2016. Average follow-up was 46.9 months. There was a documented recurrence of entropion in 1 eyelid during the follow-up period (1.4%). The remaining 69 cases had successful subjective and objective results without need for any additional procedures. In the group undergoing entropion repair without fat resection, 22 eyelids of 19 patients had the required follow-up period with a recurrence rate of 4.5% ( p > 0.05).
Conclusions:
The authors demonstrate good surgical success with a combined approach of a modified Bick procedure, preseptal orbicularis excision, and conservative orbital fat resection. Conservative fat resection during entropion repair was found to be safe, and the combined procedure was found to be effective with a rate of recurrent entropion of 1.4% on extended follow-up.
The authors propose that orbital fat prolapse contributes to the mechanics of involutional entropion and that conservative orbital fat resection during surgical repair of entropion can be done safely, resulting in low recurrence rates.

A Modified Levator Resection to Improve Postoperative Lagophthalmos and Eyelid Lag
Al-Faky, Yasser H.; Abu El-Eneen, Mohamed A.; Selim, Khaled M.; More
Ophthalmic Plastic and Reconstructive Surgery. 36(1):38-44, January/February 2020.
Purpose:
To assess the effect of releasing the central attachment between the Whitnall’s ligament (WL) and the levator palpebrae superioris muscle on the postoperative levator function (LF), eyelid lag, and degree of lagophthalmos.
Methods:
This retrospective case-control study included patients with moderate and severe simple congenital ptosis who underwent skin approach levator aponeurosis resection (LR) as a primary procedure with a minimum of 6-month follow up. Patients were divided into 2 groups; the first group underwent LR without WL release (control group) while the second group underwent LR with WL release. Preoperative demographics and clinical data were reviewed. Postoperative LF, eyelid lag, and degree of lagophthalmos as well as surgical outcomes were compared and analyzed in both groups.
Results:
A total of 81 patients (88 eyelids) were included in this study. There were 50 males (61.7%). The mean age was ±SD 12.0 ± ۹.۵ years. The first group included 43 eyelids while the second had 45 eyelids. There was no statistical difference in demographics and preoperative data between both groups. The postoperative LF was higher in the second group (10.7 ± ۲.۱ mm) with less consecutive eyelid lag compared with the control group (7.8 ± ۱.۹ mm) ( p < 0.001). The control group had acquired more postoperative lagophthalmos compared with the second group ( p < 0.001). Complete surgical success was achieved in 82.2% in the second group compared with 60.5% in the control group ( p = 0.024).
Conclusions:
Releasing the central attachment between WL and levator palpebrae superioris muscle has achieved an improvement in LF with minimal postoperative eyelid lag, lagophthalmos, and corneal complications.
Releasing the central attachment between levator palpebrae superioris muscle and Whitnall’s ligament during levator aponeurosis resection allows better levator excursion and minimizes postoperative lagophthalmos, eyelid lag, and corneal complications.

Blepharoptosis and Cholesterol-Lowering Medications: A Retrospective Study
Lam, Aimee N.; Thayer, Jessica N.; Rahman, Effie Z.; More
Ophthalmic Plastic and Reconstructive Surgery. 36(1):86-88, January/February 2020.
Purpose:
To investigate the prevalence and frequency of patients with blepharoptosis who take anticholesterol therapies. To our knowledge, this is the first large single-center series to evaluate this association.
Methods:
A retrospective chart review of adult patients presenting with ptosis on concomitant anticholesterol medications.
Results:
Two hundred ninety-three adult patients with ptosis taking anticholesterol therapy were identified from October 2011 to October 2016. Forty-seven patients (16.0%) reported muscle weakness. Laboratory markers including creatine kinase (CK) and myoglobin levels were obtained. Of the 47 patients, 13 patients (4.4%) were identified to have ptosis and laboratory confirmed anticholesterol therapy-induced myopathy. Two additional patients with statin-induced myositis and rhabdomyolysis were identified from the period 2008–۲۰۱۱. All patients had measurably elevated CK and/or myoglobin levels. All patients experienced improvement in ptosis or systemic symptoms after discontinuation or changing medications. Nine patients (60%) demonstrated statistically significant improvement in the ptosis.
Conclusions:
Many patients with involutional ptosis also have both cardiovascular disease and hyperlipidemia and thus take cholesterol-lowering medication. Our study demonstrates a World Health Organization-defined probable association between ptosis and anticholesterol-induced myopathy. The frequency of anticholesterol-induced myopathy in adult ptosis was 4.4%, which is substantially higher than previously predicted. Anticholesterol-induced myositis can cause a reversible ptosis, and thus, a thorough evaluation of adult patients presenting with involutional ptosis includes inquiry into the use of anticholesterol drugs and associated muscle weakness.
Anticholesterol medication may induce or exacerbate myogenic ptosis in some individuals.