Purpose: To determine the effect of upper eyelid platinum chain implantation, with the pretarsal fixation technique, on corneal astigmatism. Methods: This is a prospective, cohort study. Fifteen eyes of 15 patients underwent upper eyelid platinum chain implantation, with the pretarsal fixation technique, for facial nerve palsy. Information recorded included patient demographics, etiology for facial palsy, weight of the implant, time from onset of paresis to upper eyelid platinum chain implantation, associated surgical procedures, and preoperative and postoperative corneal topography measurements. Results: Of the 15 patients studied, 10 were male and five were female. The mean age was 55.9 ± 13.8 years (range, 33–87 years). The most common etiology for facial palsy was acoustic neuroma. The weight of the implant ranged from 0.6 to 1.6gr (median 1.2gr). The time from onset of paresis to upper eyelid platinum chain implantation varied from 1 week to 3 months (median 1 month). Four patients had an associated procedure to correct the effect of paralytic ectropion. There was no statistically significant difference in with the rule astigmatism before and after platinum chain implantation. Conclusions: Upper eyelid platinum chain implantation, with the pretarsal fixation technique, does not appear to cause significant change in corneal astigmatism. This is contrary to data for pretarsal gold weight implantation, which does induce significant with the rule astigmatism

Baltatzis, Stefanos

Detorakis, Efstathios T.

Kandiloros, Dimitrios

Mavrikakis, Ioannis

Yiotakis, Ioannis

English

Medical Hypothesis, Discovery & Innovation (MEHDI) Journals

 
 
Med Hypothesis Discov Innov Ophthalmol. 2015; 4(1)  
 
 
 
Original Article 
Medical Hypothesis, Discovery &Innovation  
Ophthalmology Journal 
   
 
 
Corneal Topography With Upper Eyelid Platinum Chain 
Implantation Using the Pretarsal Fixation Technique 
 
Ioannis Mavrikakis 1, Efstathios T. Detorakis 2, Stefanos Baltatzis 3, Ioannis Yiotakis 4, Dimitrios Kandiloros 4 
1 Athens Eye Hospital, Athens, Greece 
2 Department of Ophthalmology, University Hospital of Heraklion, Crete, Greece 
3 1st Ophthalmology Department, University of Athens, Athens, Greece 
4 2nd Otolaryngology Department, University of Athens, Athens, Greece 
 
ABSTRACT 
Purpose: To determine the effect of upper eyelid platinum chain implantation, with the pretarsal fixation technique, on 
corneal astigmatism. 
Methods: This is a prospective, cohort study. Fifteen eyes of 15 patients underwent upper eyelid platinum chain 
implantation, with the pretarsal fixation technique, for facial nerve palsy. Information recorded included patient 
demographics, etiology for facial palsy, weight of the implant, time from onset of paresis to upper eyelid platinum chain 
implantation, associated surgical procedures, and preoperative and postoperative corneal topography measurements. 
Results: Of the 15 patients studied, 10 were male and five were female. The mean age was 55.9 ± 13.8 years (range, 33–
87 years). The most common etiology for facial palsy was acoustic neuroma. The weight of the implant ranged from 0.6 
to 1.6gr (median 1.2gr). The time from onset of paresis to upper eyelid platinum chain implantation varied from 1 week 
to 3 months (median 1 month). Four patients had an associated procedure to correct the effect of paralytic ectropion. 
There was no statistically significant difference in with the rule astigmatism before and after platinum chain 
implantation. 
Conclusions: Upper eyelid platinum chain implantation, with the pretarsal fixation technique, does not appear to cause 
significant change in corneal astigmatism. This is contrary to data for pretarsal gold weight implantation, which does 
induce significant with the rule astigmatism. 
KEY WORDS 
Corneal Astigmatism, Corneal Topography, Facial Nerve Palsy, Gold Weight Implants, Platinum Chains 
©2014, Med Hypothesis Discov Innov Ophthalmol. 
This is an open-access article distributed under the terms of the Creative Commons Attribution Non Commercial 3.0 
License (CC BY-NC 3.0), which allows users to read, copy, distribute and make derivative works for non-commercial 
purposes from the material, as long as the author of the original work is cited properly. 
 
Correspondence to: 
Dr. Ioannis Mavrikakis; Solonos 18 Kolonaki 106 73 Athens Greece; Tel: +30 210 3619006; Fax: +30 210 3619339; E-Mail: jmavrikakis@yahoo.co
INTRODUCTION 
Surgical loading of the upper eyelid helps gravity-assisted 
closure in paralytic lagophthalmos. Since its introduction 
by Sheehan (1), several materials have been used, 
including lead (2), gold (2–8), and platinum (9). Gold is 
now the most widely used material because of its high 
density, malleability, minimal tissue reactivity, and color 
compatibility with skin. 
 
 
Med Hypothesis Discov Innov Ophthalmol. 2015; 4(1)  
 
 10 PLATINUM CHAIN IMPLANTATION AND ASTIGMATISM 
However, implantation of gold weight can affect the 
contour of the upper eyelid. It could also increase the 
degree of eyelid-cornea contact. Therefore, it seems 
plausible that this procedure might alter corneal 
curvature and affect the patient’s refractive error. A 
recent study demonstrated that pretarsal gold weights 
induce a statistically significant increase with the rule 
corneal astigmatism (10). In attempts to identify 
methods of minimizing the induction of with the rule 
corneal astigmatism associated with surgical loading of 
the upper eyelid efficiently, we conducted the current 
study in which we use platinum chains implanted 
pretarsaly. 
The purpose of this study is to evaluate any changes in 
corneal topography after platinum chain implantation in 
patients with seventh cranial nerve palsy. 
 
MATERIALS AND METHODS 
This is a single-center, prospective cohort study. All 
eligible patients undergoing upper eyelid platinum chain 
implantation for facial nerve palsy at the Athens Eye 
Hospital, Athens, Greece, were enrolled. Patients were 
examined over a 3-year period, from 2010 to 2012. 
Inclusion criteria were platinum chain implantation, 
informed consent, and lagophthalmos of 2 mm on forced 
closure. An exclusion criterion was severe corneal 
disease preventing reliable corneal topography 
measurements either preoperatively or postoperatively. 
As a result, of 20 eligible patients, 18 were enrolled in 
this study while three were lost to follow-up. We 
recorded all patient demographics, etiologies for facial 
nerve palsy, time from onset of paralysis to chain 
implantation, weight of the chain, associated surgical 
procedures and preoperative and postoperative corneal 
topography measurements. 
All platinum chains (Fig. 1) were implanted by one 
surgeon (IM). The weight was determined during the 
preoperative consultation, when it was adhered to the 
upper eyelid in the area overlying the tarsus with benzoin 
solution, and eyelid closure was assessed in the upright 
position (11). The weight was sized up or down as 
needed to achieve adequate closure without significant 
ptosis (10). 
 
Figure 1. Platinum Chain Implant 
 
Surgical procedures were performed under local 
anesthesia. The approach was through a supratarsal skin 
crease incision and dissection was carried through the 
orbicularis muscle to the tarsal plate. A pocket 
approximately the size of the implant was created over 
the tarsus, staying at least 2 mm superior to the eyelid 
margin. The appropriate implant was placed in the 
pocket, centered medial to the midpupillary line, and 
sutured directly to the tarsus with two 6–0 Vicryl sutures 
through the medial and lateral holes. The orbicularis 
muscle and skin were then closed in layers with 
interrupted 6–0 Vicryl sutures. Antibiotic ointment was 
placed over the wound, and a double eye pad applied for 
24 hours (10). 
Corneal topography was performed with an Eyemap EH-
290 (Alcon Surgical Inc., Ft Worth, TX). An absolute scale 
using 45 colors was used to display dioptric power in 0.25 
diopter steps (midpoint value 45.00). We assessed the 
keratometry (K) readings at 0º, 90º, 180º, and 270º at 3, 5 
and 7 mm diameter zones before and after implantation 
of the platinum chain in the upper eyelid. The amount of 
with the ruler astigmatism was calculated by subtracting 
the mean of the K readings at 0˚ and 180˚ from the mean 
of the 90˚ and 270˚ meridians at the 3mm optical zone 
which is the most visually relevant (10). The change in a 
vertical steepness was calculated by subtracting the with 
the rule astigmatism pre platinum chain implantation 
 
 
Med Hypothesis Discov Innov Ophthalmol. 2015; 4(1)  
 
 11 PLATINUM CHAIN IMPLANTATION AND ASTIGMATISM 
from the amount post-implantation (10). Corneal 
topography was performed at least 3 months post 
insertion of the platinum chain. Most patients required 
installation of topical lubricants to achieve, where 
possible, a stable tear film for performing corneal 
topography. Refractions were not carried out in this 
study, as it was thought that this particular group of 
patients with poor blink reflex disrupted tear film, and 
corneal exposure problems are difficult to assess 
accurately. 
Data were analyzed using SPSS software, version 13 
(SPSS Inc.). The significance of the changes in corneal 
astigmatism was evaluated using a paired T-test while 
the difference in K measurements for all zones between 
pre and post platinum chain implantation was assessed 
using the Wilcoxon Signed Ranks test. Institutional 
Review Board approval was obtained for this study. 
 
RESULTS 
Of the 15 patients, 10 were male (66.6%), and five were 
female (33.3%). The mean patient age was 55.9 ± 13.8 
years (range, 33–87 years). Tumors caused facial nerve 
paralysis in 11 cases (10 with acoustic neuroma and one 
with parotid tumor). There was also one case each 
caused by cerebral vascular accident, idiopathic Bell’s 
palsy, Ramsay Hunt syndrome, and polio. 
The weight ranged from 0.6 to 1.6 gr (median 1.2 g). The 
time from onset of paralysis to upper eyelid platinum 
chain implantation varied from 1 week to 3 months 
(median 1 month). Four patients had an associated 
procedure during the upper eyelid platinum chain 
implantation to correct the effect of paralytic ectropion. 
Of these, 3 had a lateral tarsal strip and mid face lift, and 
one had a lateral tarsal strip alone. There was no 
statistically significant difference in K measurements for 
any zone between pre and post platinum chain 
implantation and in the changes in corneal astigmatism. 
The pre and post-implantation keratometry readings and 
change in with the rule astigmatism for the 3 mm zone 
for each patient are shown in Table 1. 
 
DISCUSSION 
In this study, we evaluate any changes in corneal 
topography after upper eyelid platinum chain 
implantation in patients with seventh cranial nerve palsy, 
using the pretarsal fixation technique. Masses arising in 
the eyelid can cause pressure on the corneal surface with 
distortion of its topography. Such lesions cause flattening 
of the globe directly under the area of compression with 
steepening of curvature adjacent to the area of 
compression. Eyelid lesions such as hemangiomas and 
large chalazia may induce central or paracentral 
compression, whereas more peripheral flattening is 
induced by masses at or behind the limbus such as 
dermoids or explants from retinal surgery. The 
association between astigmatism and upper eyelid 
abnormalities, such as congenital ptosis (12), 
hemangiomas (13, 14), and chalazia (15) has been 
documented. 
Pretarsal gold weight implantation also induces corneal 
astigmatism. More specifically, it was found that, with 
the rule corneal astigmatism increased significantly by 
1.4 diopters ± 2.0, from a mean of 0.3 to 1.7 D after gold 
weight implantation (p=0.034) (10). The astigmatism is 
usually mild and can be corrected with spectacles. 
However, it has been previously found that patient 
satisfaction following gold weight implantation correlates 
closely with post-implantation visual acuity (16). 
Therefore, a surgical technique that reduces induced 
astigmatism may significantly improve patient 
satisfaction. 
 
  
 
 
Med Hypothesis Discov Innov Ophthalmol. 2015; 4(1)  
 
 12 PLATINUM CHAIN IMPLANTATION AND ASTIGMATISM 
Table 1. With the Rule Astigmatism Pre and Post Platinum chain Implantation 
 
 
In our study, we found that when using platinum chain 
implantation with the pretarsal fixation technique, no 
significant change occurred in the amount of corneal 
astigmatism (p=0.822). This may be because the 
platinum chain is flexible and adapts better to the 
changing radius of the tarsus with movement of the 
globe, in contrast to gold weights which are rigid (9). 
Another possible explanation is that the density of 
platinum differs from that of gold. As a result, for the 
same weight, the volume of a platinum implant is smaller 
than that of one in gold. There have been studies 
reporting the reduction of the side effect of corneal 
astigmatism using platinum chains with the pretarsal 
fixation technique (9,17). However, to our knowledge, 
there have been no studies published describing the 
effect of upper eyelid platinum chain implantation on 
corneal topography. 
Other methods reported in the literature that have been 
shown to reduce the side effect of corneal astigmatism 
use gold weights with the combined high pretarsal and 
levator fixation technique (18,19). This may be because 
Patient 
 
Preoperative Keratometry 
  (Diopters) 
With the Rule 
Astigmatism 
(diopters) 
Postoperative Keratometry 
(Diopters) 
With the Rule 
Astigmatism 
(Diopters) 
Change in With the 
Rule Astigmatism 
(Diopters) 
 Axis 
0ο 
Axis 
90ο 
Axis 
180ο 
Axis 
270ο 
 Axis 
0ο 
Axis 
90ο 
Axis 
180ο 
Axis 
270ο 
  
1 41.96 41.87 37.51 42.86 2.63 41.75 42.24 41.87 42.45 0.535 -2.095 
2 40.29 46.17 41.15 44.87 4.8 39.99 42.81 39.48 41.07 2.205 -2.595 
3 42.47 44.18 42.35 43.95 1.655 42.68 43.70 42.30 46.71 2.76 1.105 
4 45.22 45.89 44.30 47.56 1.965 45.18 48.39 44.15 45.97 2.515 0.55 
5 43.11 42.63 42.79 42.90 -0.185 41.49 40.20 42.06 42.04 -0.655 -0.47 
6 42.06 46.12 45.19 47.52 3.195 45.48 48.88 46.31 45.92 1.505 -1.69 
7 43.78 43.91 43.98 44.37 0.26 43.77 43.99 43.50 46.29 1.505 1.245 
8 46.05 46.20 47.41 49.05 0.895 48.27 45.23 47.26 48.66 -0.82 -1.715 
9 46.57 42.15 39.16 42.25 -0.665 41.64 44.77 44.42 47.55 3.13 3.795 
10 41.57 43.28 41.32 41.64 1.015 44.46 47.42 42.42 40.10 0.32 -0.695 
11 43.33 39.87 30.58 42.30 4.13 42.55 43.13 38.66 43.99 2.955 -1.175 
12 47.33 41.14 49.00 43.45 -5.87 40.67 38.78 39.01 38.67 -1.115 4.755 
13 46.17 47.15 40.12 46.19 3.525 46.10 50.50 45.04 44.63 1.995 -1.53 
14 39.48 40.41 41.01 46.65 3.285 38.63 40.68 39.51 42.20 2.37 -0.915 
15 39.55 41.07 38.94 39.65 1.115 39.88 40.04 39.17 40.35 0.67 -0.445 
Mean     1.45     1.325 -0.125 ± 2,1 
Pvalue           p=0.822 
 
 
Med Hypothesis Discov Innov Ophthalmol. 2015; 4(1)  
 
 13 PLATINUM CHAIN IMPLANTATION AND ASTIGMATISM 
the position of the implant is above the cornea and not in 
direct contact with the globe when the eye is open, 
inducing less corneal warpage (18,19). In conclusion, 
implantation of a platinum chain in the upper eyelid, in 
patients with facial nerve palsy, using the pretarsal 
fixation technique appears to significantly reduce the 
adverse effect of corneal astigmatism associated with 
pretarsal gold weight implantation. 
 
DISCLOSURE 
Conflicts of Interest: None declared. 
 
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Corneal Topography With Upper Eyelid Platinum Chain Implantation Using the Pretarsal Fixation Technique

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Corneal Topography With Upper Eyelid Platinum Chain Implantation Using the Pretarsal Fixation Technique

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