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Preoperative phenylephrine testing as a predictor of postoperative eyebrow
position
Tal J. Rubinstein1,
Austin J. Woolley2, Bryan R. Costin1,
Julian D. Perry1
1Cole Eye Institute, Cleveland Clinic Foundation,
Cleveland, OH 44195, USA
2Case Western Reserve University School of Medicine, Cleveland, OH 44106,
USA
Correspondence to: Julian D. Perry. Cole Eye Institute, Cleveland Clinic Foundation, 2022 E. 105th St. Cleveland, OH 44195, USA. perryj1@ccf.org
Received:
2014-08-22
Accepted: 2015-08-05
DOI:10.18240/ijo.2016.03.27
Citation: Rubinstein TJ, Woolley AJ, Costin BR, Perry JD. Preoperative
phenylephrine testing as a predictor of postoperative eyebrow position.
Int
J Ophthalmol 2016;9(3):472-474
Dear Sir,
Eyebrow position and contour
strongly influences overall facial cosmesis[1-3]
and depends on many factors, including age, gender, ethnicity, superior sulcus
depth, frontal sinus pneumatization, prior surgery, and cultural trends[3-9]. Repair of blepharoptosis
or dermatochalasis may diminish compensatory eyebrow elevation, thereby
lowering eyebrow position postoperatively[10-11]. The preoperative blepharoptosis discussion with a patient should include
possible effects on eyebrow position[10]. However, to our knowledge, no method exists to
predict the amount of eyebrow descent that may occur in order to guide this
discussion. We commonly employ preoperative phenylephrine testing in cases of
conjunctival-Müllerectomy with or without tarsectomy (CM±T) blepharoptosis
repair to determine the appropriate amount of tissue resection[12]. In our
experience, the ipsilateral eyebrow often descends following a positive
phenylephrine test. Given that phenylephrine testing may predict final eyelid
position using our algorithm for CM±T blepharoptosis repair[13], we sought to determine whether such testing predicts
postoperative eyebrow position.
We retrospectively reviewed
the charts of all patients undergoing unilateral CM±T blepharoptosis repair at
the Cole Eye Institute between July 2012 and October 2013. Exclusion criteria
included concurrent or previous upper eyelid/eyebrow surgery or trauma;
inadequate or missing photographs; known history of Graves’ disease, Horner’s
syndrome, Myasthenia Gravis, 3rd nerve palsy, 7th nerve
palsy, or infiltrative blepharoptosis; history of topical alpha-agonist use;
concurrent periocular neurotoxin injection; and follow-up interval of less than
6-week duration.
All surgeries were performed
according to a previously published tissue resection algorithm and technique by
one surgeon (Perry JD)[12]. Preoperative, post-phenylephrine, and postoperative
digital photographs were analyzed for each patient. ImageJ software (National
Institute of Health, Bethesda, MD, USA) was used to measure distances in pixels, and these measurements were
converted to millimeters using a previously published technique[13]. Measurements included marginal-reflex distance (MRD1), lateral brow
height (LBH), central brow height (CBH), and medial brow height (MBH; Figure
1). Follow-up interval was measured between date of surgery and date of last
postoperative photograph used for analysis. Two-tailed paired Student’s t-test and
Pearson product correlation were used for data analysis.
Figure 1 Image measurements a: MRD1; b: LBH; c: CBH; d: MBH.
Seventy patients underwent unilateral CM±T blepharoptosis repair during the
study period; 61 patients were excluded, mostly for inadequate or incomplete
photographs (41 patients) and concurrent or prior upper eyelid or brow surgery (15 patients), leaving 9 patients for inclusion in the study.
There were 8 female patients and 1 male patient. Average patient age was 58y
(range 34-85y). Average follow-up time between preoperative and postoperative
photographs was 2.8mo (range 1.3-9.5mo). Table 1 summarizes the average
ipsilateral and contralateral MRD1, LBH, CBH and MBH preoperatively, after
phenylephrine testing, and after surgery.
Linear regression plots between the change in ipsilateral MRD1, LBH,
CBH, and MBH after phenylephrine testing and following surgery with respective
linear equations are demonstrated in Figure 2.
Table 1 Preoperative,
post-phenylephrine, and postoperative eyelid and brow heights
mm
|
Eyelid |
MRD1
mean (range) |
LBH mean (range) |
CBH mean
(range) |
MBH mean
(range) |
|
Ipsilateral
(surgical) side |
||||
|
Preoperative value |
1.56 (0.25-3.26) |
19.3 (10.21-25.4) |
15.0 (6.69-20.9) |
15.3 (7.71-20.1) |
|
Post-phenylephrine value |
3.00 (0.61-5.16)a |
17.5 (9.17-25.5)a |
13.9 (6.44-18.5) |
14.1 (8.19-18.8)a |
|
Postoperative value |
3.13 (1.11-5.44)a |
18.2 (9.69-25.7)a |
14.4 (6.92-18.9) |
14.8 (8.44-18.4) |
|
Pearson product correlation |
0.69 |
0.26 |
0.64 |
0.66 |
|
Contralateral
(nonsurgical) side |
||||
|
Preoperative value |
3.04 (1.77-4.36) |
17.2 (6.80-26.8) |
14.4 (6.01-19.6) |
14.8 (7.48-17.0) |
|
Post-phenylephrine value |
3.13 (1.07-4.04) |
17.3 (6.22-27.8) |
14.5 (7.21-19.3) |
14.7 (8.41-17.0) |
|
Postoperative value |
3.02 (2.21-4.62) |
18.1 (8.86-27.6)a |
14.4 (5.40-18.3) |
15.1 (8.72-18.0) |
|
Pearson product correlation |
0.42 |
0.15 |
0.66 |
0.57 |
aStatistically
significant (P<0.05) by Student’s
paired t-test compared to preoperative
value. Pearson product correlations are between the change in each value after
phenylephrine testing (preoperative, post-phenylephrine)
and postoperatively (preoperative-postoperative). MRD1:
Margin-to-reflex distance; LBH: Lateral brow height;
CBH:
Central brow height; MBH: Medial brow height.
Figure
2 Linear regression plots of change in ipsilateral eyelid and eyebrow heights Linear regression for change in
ipsilateral MRD1 (A), LBH (B), CBH (C) and MBH (D). Y-intercept set at (0,0).
Predicting postoperative
brow descent is critical, especially in cases of longstanding blepharoptosis
where significant frontalis muscle compensation may exist. In this study, we
found clinically modest, but statistically significant, changes in ipsilateral
and contralateral eyebrow position after both phenylephrine testing and
surgery. We found a moderate to high correlation between post-phenylephrine and
postoperative central and medial eyebrow height, suggesting that phenylephrine
testing helps predict postoperative eyebrow position in cases of unilateral
blepharoptosis repair. Linear regression showed that the ipsilateral eyebrows
relax approximately twice as much following phenylephrine testing than after
surgery. Revealing this exaggerated eyebrow descent in the mirror to the
patient after phenylephrine testing plainly demonstrates this possible unwanted
effect of surgery to the patient.
We studied unilateral cases
of blepharoptosis repair with no history of previous or concurrent surgery,
trauma or topical therapy in order to attempt to isolate the variables of
post-phenylephrine testing and postoperative measurements as best as possible.
We used digital measurements to objectively measure the eyelid and eyebrow
position. Digital photography may not best capture true eyelid or eyebrow
positions, which are dynamic in nature, but we do not routinely measure brow
position in clinic, and no standard yet exists for clinical brow position
measurement. Using digital photographs reduced the n of this study; however, several variables still
achieved statistical significance.
While eyebrow position
lowered on average only 1-2 mm after phenylephrine testing in any given
position, the resultant resolution of brow compensation may be expected to be
somewhat modest in this group of patients who underwent relatively mild
blepharoptosis correction. Indeed, the average preoperative MRD1 was over 1.5
mm. It seems likely that phenylephrine testing would demonstrate even greater
amounts of eyebrow descent in patients with more severe blepharoptosis and
frontalis muscle compensation.
We did not routinely measure
ocular dominance, which may affect the presence of unilateral frontalis muscle
compensation[14]. It is
possible that treating blepharoptosis ipsilateral to the dominant eye may
affect eyebrow height differently compared to treating blepharoptosis
contralateral to the dominant eye. It is also unclear whether phenylephrine
testing may accurately predict eyebrow position after bilateral blepharoptosis
repair.
Phenylephrine testing may
help predict postoperative eyebrow position in cases of unilateral CM±T blepharoptosis repair. This information can guide
the patient discussion and surgical plan. Further studies may determine its
usefulness in cases of levator advancement ptosis repair, bilateral cases, and
cases undergoing concomitant surgery.
ACKNOWLEDGEMENTS
Conflicts of Interest: Rubinstein TJ, None; Woolley AJ, None; Costin BR, None; Perry JD, None.
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