Blepharophimosis–ptosis–epicanthus inversus syndrome: objective analysis of surgical outcome in patients from a single unit


Mr Anthony G. Tyers, Ophthalmology Department, Salisbury District Hospital, Salisbury, Wiltshire SP2 8BJ, UK. Email:;


Background:  The aim was to objectively assess surgical outcome in blepharophimosis–ptosis–epicanthus inversus syndrome (BPES).

Method:  Retrospective review of 14 consecutive patients with BPES. Mustardé double z plasty (at about age 4) and autogenous fascia lata Crawford brow suspension (9–12 months later) were used in all. One consultant performed all operations. Patient photographs were scanned and magnified for analysis. Preoperative and postoperative intercanthal distance, vertical palpebral aperture and cosmetic outcome were measured. Values were converted into ratios.

Results:  Bilateral (mildly asymmetrical) ptosis and symmetrical epicanthic folds were found in all preoperatively. Seventy-one per cent had severe folds. Preoperative intercanthal distance ratio range was 1.26–1.60 (non-BPES = 1.0). Median reduction post surgery was 26% (P = 0.001, Wilcoxon’s signed ranks test). Patients with largest preoperative ratio displayed greatest correction (P = 0.029). Mustardé technique completely abolished all epicanthic folds and unmasked prominent caruncles in all. Fifty per cent had mild scarring postoperatively in the medial canthal region. Median change in marginal reflex distance ratio (right) = 22.2% (P = 0.012), left = 18.2% (P = 0.008), Wilcoxon’s signed ranks tests. Postoperatively all had formed eyelid creases with improved upper lid position symmetry.

Conclusions:  This is the first known study objectively assessing surgical outcome in BPES. Mustardé double z plasty and Crawford autogenous fascia lata brow suspension are an effective surgical combination in the treatment of this syndrome, with overall cosmetic benefit.