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    Opthalmology:
 

Ptosis Correction Surgery

The damaged cornea is removed and the corneal graft is stitched in place. The corneal graft is a transplant from a brain dead donor maintained on life support.


Problem:

Congenital

Congenital ptosis is usually a result of fibrous and fatty tissue replacing the normal muscle fibers; these fibers are inelastic and lead to poor function and lagophthalmos on downgaze. Deciding the best procedure for a patient is easiest when the patient has simple congenital ptosis, whether mild or severe. Patients with congenital ptosis are born with the problem; their ptosis remains relatively constant throughout the first few years of life or until surgery is performed, and their levator function is generally compatible with the degree of ptosis observed clinically. In general, mild ptosis (1-2 mm) is accompanied by good levator function (>8 mm), moderate ptosis (3 mm) has fair levator function (5-7 mm), and severe ptosis (>4 mm) has poor levator function (<4 mm). Levator resection is the procedure of choice for patients with congenital ptosis when reasonable levator function is present. The amount of resection can be small (10-13 mm), medium (14-20 mm), or large (21-26 mm) and can be tailored to be smaller or larger depending on the levator function (ie, a patient with 7 mm of levator function and 3 mm of ptosis requires a smaller resection than a patient with 3 mm of ptosis and 5 mm of levator function). At the time of surgery, the levator tendon is generally shortened until the lid is at the level the surgeon would like it to be postoperatively (much the way the lid level is set during the frontalis sling procedure). In patients with poorer levator function, setting the lid 1-2 mm higher may be appropriate, since these lids have a tendency to drop postoperatively. The amount of resection necessary in these patients is usually greater than 20 mm.

If the ptosis was slight and levator action good, the Fasanella Servat procedure, which excises the tarsus, conjunctiva, Müller muscle, and perhaps levator tendon, gained widespread popularity because of its relatively simple nature. Some textbooks still discuss the use of the superior rectus muscle in ptosis surgery, but this procedure never should be performed. More recently, the aponeurotic technique for shortening the levator tendon has become the commonly accepted approach.

Marcus Gunn (jaw-winking) ptosis

Some forms of ptosis warrant individual consideration. Probably the most common and one of the most difficult to manage forms of ptosis is the jaw-winking syndrome (Marcus Gunn phenomenon). All patients with jaw-winking syndrome exhibit a variable degree of ptosis of the involved lid when the eyes are at rest in the primary position. The wink reflex consists of a rapid elevation and retraction of the lid to a higher level than that of the normal fellow lid and an almost equally rapid return to a less elevated level. The involved lid then may remain for a time at the height of the normal lid or may droop to the original ptotic position. The rapidity of the motion produces a bizarre appearance that is disturbing to the patient and observers.

The wink may be produced by sucking, swallowing, chewing, or lateral motion of the jaw to either side. The phenomenon is the result of an abnormal connection between the motor branches of the fifth cranial nerve (the pterygoid branch) and the superior division of the oculomotor nerve, which innervates the superior rectus-levator complex. Studies suggest that a central nervous system abnormality is underlying the anatomic defect in both the affected and clinically uninvolved sides.

The patient (if of appropriate age), parents, and ophthalmologist must decide whether the ptosis or the wink is responsible for the greater cosmetic blemish. If the ptosis is the more striking defect, elevate the lid by shortening the levator aponeurosis. However, this procedure is satisfactory only if the wink is a minimal part of the problem. Because the ptosis is usually mild to moderate, resection is a satisfactory procedure; however, the patient and parents must understand the mechanics of the problem and fully realize that shortening the levator, although improving the appearance of the ptosis in the primary position, also increases the height of excursion of the wink.

If the wink is the major cosmetic blemish, as it often is, it may be corrected in one of several ways. At this time, the most acceptable method of correcting the wink involves severing the levator tendon to destroy its action and then performing a fascia lata sling. Bilateral procedures, which cut the levator tendon of both the affected and the normal lids and suspend both lids from the frontalis muscle, yield a more attractive and symmetric result. Dryden and coworkers have advocated suturing the levator aponeurosis to the linea alba at the upper orbital rim to ensure its deactivation. This procedure does not destroy the levator tendon and muscle, which can be reactivated if, for some reason, reactivation is desired.

Surgery may be delayed for an observation period, since the Marcus Gunn phenomenon has been said to disappear in adulthood. This assumption apparently has been based on the impression that few adults are seen with the condition. In fact, such patients do exist; their apparent scarcity probably is because of prior surgery or a reluctance to continue visiting ophthalmologists for consultation about this problem. Although some decrease in the wink may occur, it does not universally disappear in adulthood.

Acquired

Traumatic and iatrogenic ptosis

Adults with acquired ptosis secondary to levator tendon disinsertion or dehiscence may develop the problem either spontaneously or after minor trauma, allergic reactions, or surgery (this is the cause of postoperative, or postcataract, ptosis). The degree may be mild, with only 1-1.5 mm of ptosis, or severe, with a complete ptosis in which the patient is unable to open the eye. Generally, levator function is relatively good, and the ptosis remains essentially the same in both upgaze and downgaze, which readily differentiates it from the inelastic levator muscle typical of congenital ptosis. The lid crease is generally present and is often slightly higher than on the uninvolved side. Additionally, the upper sulcus is frequently deeper than on the uninvolved side, also indicating the diagnosis.

Acquired ptosis with levator dehiscence requires a simple repair to restore normal lid position and function. This is accomplished by reattaching the dehisced edge of the levator aponeurosis to the normal position on the anterior tarsus without resecting any portion of its tendon. Resection of the levator tendon in the presence of a normal muscle leads to overcorrection of the lid position. Overcorrections are observed with some frequency in acquired ptosis because of levator dehiscence, whereas they are difficult to obtain in simple congenital ptosis.

Traumatic ptosis may have 3 possible etiologies. Mild degrees of trauma associated with edema or hemorrhage may produce a levator disinsertion that can be readily repaired using an aponeurotic approach, as described above. Lacerations of the lid may sever the levator tendon, leading to scarring and secondary mechanical ptosis. This problem is best managed by careful repair of the levator aponeurosis at the time of primary repair of the lid injury. If this is not accomplished, often the orbit can be explored at a later time and the levator muscle identified and repaired.

The third major variety of traumatic ptosis involves damage to the nerve supply of the levator muscle. Since the levator and the superior rectus muscle are commonly innervated, such injuries may affect the elevation of the eye, including Bell phenomenon. In this situation, allow at least 6 months to 1 year to pass prior to performing any surgery, since some degree of regeneration often occurs. After this period, a levator resection or sling procedure can be performed, depending on the severity of ptosis and the degree of return of levator muscle function.

If aberrant regeneration is present (as often occurs after damage to the oculomotor nerve) and lid function is significantly abnormal, consider a procedure similar to that described for Marcus Gunn ptosis; however, exercise caution because the abnormal ocular motility may predispose the patient to corneal exposure related to the expected postoperative lagophthalmos.

Neurogenic/myogenic ptosis

Acquired ptosis that is not associated with levator tendon dehiscence or trauma is a difficult problem. Myasthenia gravis, ocular-pharyngeal syndrome, idiopathic late-onset familial ptosis, progressive external ophthalmoplegia, and other neurogenic entities fall into this category. The ptosis of myasthenia gravis is usually managed medically and is not discussed in further detail.

The ptoses in the myogenic group are generally progressive and have a high frequency of recurrence despite repeated surgery, including levator resections. When additional surgery is contemplated for patients who have adequate tear secretion and orbicularis muscle function, consider a frontalis sling procedure. Surgery should be performed in these patients with the patient under local anesthesia whenever possible to allow intraoperative adjustment of the lid position with consideration of the degree of lagophthalmos that can be tolerated in that individual. Consider purposeful undercorrection in these patients.

Mechanical ptosis

Many patients with tumors of the lid or orbit may present with ptosis, and the surgeon should be aware of such problems when evaluating any patient with acquired ptosis.

Blepharophimosis ptosis syndrome

The last major subgroup that presents some difficulty in management is the autosomal dominant–inherited syndrome of blepharophimosis ptosis. Patients with this syndrome have blepharophimosis, severe ptosis (usually with no levator function), epicanthus inversus, and ectropion of the lateral portions of the lower lids. The ptosis is corrected by frontalis fixation at an early age. Canthoplasties may be performed to improve the blepharophimosis. The considerable epicanthus is usually best left until early adolescence, since the degree of this problem tends to diminish with time, and the skin becomes more supple and easy to move. The author has found Mustarde double Z-plasty the most effective method of correcting this problem.

In most instances, the primary reason for correcting congenital ptosis is cosmetic. Most surgeons agree that significant congenital ptosis should be repaired by age 5 years or before the child begins regular school. An exception to this timing is found in patients with severe bilateral ptosis that interferes with the child's ability to learn how to walk. The levator action in these children is always so poor that a frontalis sling procedure is necessary. Another exception is found in patients with unilateral congenital ptosis of such severity that normal visual development is compromised by total occlusion of the visual axis, in which instance surgical intervention may be indicated shortly after birth. Finally, patients who previously managed bilateral congenital ptosis using a chin-up head position may decompensate with discontinuation of the head-up position; this a sign of development of amblyopia, which must be treated urgently with surgical correction of the ptosis and amblyopia management.

In patients with acquired or secondary ptosis (eg, involutional or traumatic cases, ptosis associated with generalized disease or tumor), surgery often is recommended when the patient's daily activities are compromised by occlusion of the visual axis, superior visual field is lost, or extreme fatigability occurs while reading, among other difficulties.

Vision may be affected in patients with secondary ptosis and sometimes in patients who have slight ptosis. During the preoperative evaluation, the physician must determine if visual or asthenopic components of the ptosis are present that indicate the need for surgery. Thorough documentation of symptoms, field defects, and submission of clinical photographs are now required routinely by third-party payers.

Imaging Studies:

CT scanning of orbits should be considered in patients with acute ptosis or if any suspicion of an orbital process, sulcus filling, or exophthalmos exists.

Other Tests:

  • Visual acuity: Careful vision testing is performed using an age-appropriate method. In the past, ptosis alone was not considered to produce amblyopia, and other associated factors (eg, anisometropia, strabismus) were always thought to be the cause. However, recent studies have documented that amblyopia is possible with an isolated ptosis. This problem should be searched for and treated as necessary.
  • Orthoptic evaluation: Look for associated problems (eg, double elevator palsy) or other more common forms of strabismus. If indicated, muscle surgery can be performed at the same time as ptosis surgery.
  • Visual field: Obtain visual field tests in patients who are able to cooperate in order to document peripheral and superior visual field restriction.
  • Slit lamp examination: Include slit lamp examination, intraocular pressure measurement, and fundus examination in the preoperative evaluation.
  • Refraction: A cycloplegic refraction is indicated in all children with ptosis, since a significant number of them have anisometropia primarily due to astigmatism on the ptotic side. Correct any significant refractive error.
  • Tear function testing: In adults, obtain a measure of basal tear secretion by performing a Schirmer test of the anesthetized eye. In addition, evaluate the corneal tear film for evidence of abnormal debris or tear breakup.

Ptosis measurements

Simple observation: Begin with simple inspection of the patient. Observe the lid level relative to the globe and to the other lid. The presence or absence of a lid fold or lid crease gives a significant clue to the degree of levator function. An absent lid crease is often accompanied by poor levator function. If a lid crease is present but is higher than normal (a normal lid crease is 8-10 mm from the lid margin measured above the pupil) and if a deeper upper lid sulcus is found on that side, note these as signs of a levator aponeurosis disinsertion. When the patient is asked to look up, both the sulcus and the lid crease may move superiorly slightly before the lid moves. This is caused by a delay in levator action due to the attenuation or stretching of the normal aponeurotic attachments to the tarsus. Measure and record the position of both upper lid creases.

Surgical therapy: Blepharoptosis is one of the most challenging of the commonly encountered oculoplastic problems. The goal of ptosis surgery is to recreate as nearly perfect an anatomic result as possible by elevating the position of the lid or lids and by creating a lid fold, if necessary. In addition, special attention is given to the contour and symmetry of the lids.

A thorough understanding of the goals and limitations of ptosis surgery is important, and the patient should be fully aware of these before surgery is planned. Particularly in congenital ptosis, when factors inherent to the anatomic defect pose limitations to the surgical results, the expectations and goals of the surgery must be discussed carefully with the patient and/or the parents preoperatively. A defective levator muscle, whose function is abnormal or absent preoperatively, cannot be restored surgically. The lid level can be changed, but dynamic limitations of the affected muscle persist postoperatively, and these may result in significant lid lag and lagophthalmos. Often the best result that can be hoped for is a normal lid level and contour when the eyes are in the primary position. In adult-acquired ptosis, surgery may result in inappropriate eyelid closure, exacerbation of a preexisting tear deficiency, and secondary exposure keratopathy.

Preoperative details: General anesthesia is necessary for all children. Local anesthesia is adequate for adults and is much preferred for some types of ptosis. Adequate anesthesia can be obtained with a simple subcutaneous injection of 1.5-2 mL of anesthetic across the breadth of the lid. Intraorbital injection is not necessary, and if patient cooperation is desirable for setting the lid height, avoid injection behind the orbital septum. This type of injection avoids levator akinesia, thus allowing the levator muscle to function normally intraoperatively. The maintenance of levator function is an essential part of some ptosis procedures. It allows demonstration of the redevelopment of normal lid function in patients who have aponeurotic defects and is a valuable guide in patients with other syndromes in which the amount of levator resection cannot be judged accurately from preoperative measurements. Plain lidocaine (2%), lidocaine with epinephrine, or a lidocaine-bupivacaine mixture are all satisfactory.

Intraoperative details: Frontalis sling (modified Crawford technique)

Although many variations of technique and materials for the frontalis sling procedure exist, generally surgeons agree that autologous fascia lata or preserved fascia lata (as a second choice) placed as a double rhomboid, single rhomboid, or triangular sling from the frontalis to the lid produces the best result. Other materials, such as catgut, collagen, Prolene, silicone, stainless steel, silk, skin, Supramid, sclera, tantalum, tarsus, and recently Mersilene mesh, umbilical vein, tendon, and other new synthetics, have been tried. Most of these materials have resulted from a search for substitutes that are effective, easily available, inexpensive, easily placed and removed, and involve few complications. Perhaps most importantly, the hope was that these would be useful in infants or young children when autologous fascia was not available.

Many of these materials have clear disadvantages, and the author does not recommend their routine use. The primary problems include early and late failure due to absorption, stretching, fracture, or cheese wiring, as well as infection that may require removal of the foreign body, which may be difficult or impossible with Mersilene mesh. To date, none of these materials have matched fascia lata in effectiveness and safety.

Clearly, in some circumstances fascia lata may not be necessary, for example, in a young infant with congenital ptosis felt to be of traumatic origin or caused by a hemangioma and in whom a temporary lid elevation may be desired or in an adult with dry eyes and severe myogenic ptosis in whom a temporary and easily reversible procedure may be performed to assess the patient's tolerance to lid elevation.

The author recommends Supramid or Prolene suture in children and Prolene or perhaps a silicone band in adults; this may be placed in an adjustable fashion. Whatever material is used, the principle of the suspension is the same (ie, the frontalis muscle, which normally elevates the brow, is used to elevate the lid).

Crawford popularized the use of the patient's own fascia lata and developed a fascia lata stripper that bears his name. He has also devised a method for storing human fascia sterilized by radiation. Physicians have used this material since 1969, and it has produced results nearly comparable to those with autologous fascia. Crawford found a recurrence of ptosis in approximately 10% of more than 300 patients in whom this procedure was performed over a 20-year period when preserved fascia was used. For this reason, he uses autologous fascia in all but infants and elderly people. To avoid the necessity of harvesting fascia, the author generally uses the preserved material and reserves the autologous fascia for patients in whom it is unavailable or when a previous sling has failed.

Using a sling for unilateral ptosis produces a cosmetic blemish on downward gaze because the motion of the lid is restricted when following the downward movement of the globe; however, excellent cosmetic results can often be obtained with the unilateral sling. The patient can learn to move one side of the brow to set the lid level close to that of the unaffected side and can ease the brow on downgaze to minimize asymmetry. Use of a bilateral sling is now accepted in patients with unilateral ptosis or with unilateral jaw-winking phenomenon to give symmetry to the 2 lids. This is felt by some to be cosmetically pleasing and to give coordination to the movements of the lids as they follow the globe in the up and down positions.

and taped to the brow works well.

Anterior approach for levator aponeurosis repair

Local anesthesia is preferred for anterior-approach levator aponeurosis repair because it allows documentation of levator function at the time of surgery and allows the patient to cooperate with the surgeon in setting the proper height and contour of the lid(s). Resection or advancement of a tendon with a normal muscle is likely to produce an overcorrection, and local anesthesia allows for accurate determination of lid level. Lidocaine (2%) provides adequate anesthesia for this procedure, which generally takes only about 30-40 minutes to perform. Approximately 0.5-1.5 mL of lidocaine is injected subcutaneously across the lid at the level of the lid crease. Injecting posterior to the septum is not desirable, since this paralyzes the levator muscle. The skin incision and dissection through the orbicularis are the same as for a levator resection.

If a full dehiscence has occurred, often the septum is rolled superiorly and attached to the free edge of the levator aponeurosis, making its identification difficult. In this setting, after the orbicularis is divided, the Müller muscle is the next structure the surgeon encounters. The slight reddish-brown color and the transverse peripheral vascular arcade at the retrotarsal margin readily identify this muscle. If dissection is carried superiorly for several millimeters, the septum and tendon can be identified and separated. Remember that orbital fat is a crucial landmark separating these 2 structures. Dissecting superiorly under the orbicularis and over intact septum until preaponeurotic fat can be identified may be wise. At this point, the septum can be incised and the fat retracted to identify the levator aponeurosis proximal to the dehiscence.

When a complete dehiscence occurs, the edge of the levator tendon is identifiable as a relatively thick, rolled, white structure. If the patient is asked to open his or her eye or look up at this point in the procedure, the tendon is seen to retract into the orbit forcefully. After isolation, resuture the tendon to the upper mid portion of the tarsus, but slightly nasal to the pupil in the primary position, using a nonabsorbable suture. Use 2 additional sutures to set the lid contour nasally and temporally. Temporary suture placement initially allows for demonstration of good lid level and function prior to final closure. Care in closure prevents lid contour problems.

Occasionally, the levator tendon does not have a complete dehiscence but is attenuated and elastic in nature, termed a stretchy tendon. At surgery, this can often be identified by having the patient open his or her eyes and look up, demonstrating good levator function superiorly in the orbit but with poor lid motions. In this situation, simply resuture the tendon to the upper tarsal border to produce a firm attachment of the tendon to the lid at the desired height. This sometimes requires the use of hang-back sutures.

Close the skin with 8-0 black silk sutures in the same fashion as described for levator resection. The lid fold usually reforms spontaneously, but 2-3 fine sutures attaching the orbicularis to the levator tendon ensure its reformation. The author prefers not to suture skin to the tendon because this gives an unnaturally deep crease, which is noticeable when the lids are closed. No Frost suture is required.

A light patch may be used at the surgeon's discretion, although an antibiotic ointment may suffice. The author has found that the best results are obtained with minimal anesthesia and a rapid, atraumatic procedure. Postoperatively, the lids usually remain within 1 mm or so of the level set at surgery.

Postoperative details: With levator resection or a fascia sling procedure, in which some lagophthalmos is expected, the lower lid is pulled up with a modified Frost suture to cover the cornea.

Place antibiotic ointment in the eye and apply a light patch, which should be left in place for 24 hours. Use an antibiotic-steroid ointment on the suture line during the postoperative period and in the eye to guard against possible drying. Generally, only 1-2 weeks of ointment use is necessary for complete adjustment to the new situation. The patient is seen on the first postoperative day mainly to look for exposure problems and infection. If evidence of surface drying or a persistent epithelial defect is observed, the Frost suture may be left in place until healing occurs.

Follow-up care: Remove the sutures 5-7 days postoperatively and recheck the patient. If lagophthalmos seems severe and the patient is unable to close the eye, the lid may be taped closed at nighttime, or a bubble-shield moisture chamber may be placed for protection in addition to generous ointment application. Once the repair is stable, a final visit in 1-2 months allows evaluation of the result.

For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education article Black Eye.

COMPLICATIONS

Author Information Introduction Indications Relevant Anatomy And Contraindications Workup Treatment Complications Outcome And Prognosis Future And Controversies Bibliography

Poor or improperly positioned lid crease

A poor or improperly positioned lid crease may occur if the skin incision is placed incorrectly or if the skin and orbicularis muscle are not fixated to the levator aponeurosis during the skin closure. A lid crease can be lowered by making an incision at the desired level for the new crease and then excising the intervening scar and closing the new incision. Conversely, elevating the crease is difficult, since making a new adhesion higher exposes the original scar. In that situation, lowering the crease on the contralateral side may be easier.

Peaking of the lid

Peaking of the lid rarely occurs with levator resection if the tarsus is left intact, since its width serves to stabilize the lid contour. However, if sutures are placed unevenly or if suturing is directly to the tarsus in one area and to pretarsal tissues in another, contour problems are more likely to occur. Reoperation may be necessary to obtain the best result. Operations in which the tarsus is resected partially produce a much higher frequency of lid contour problems and are therefore no longer advocated.

Exposure keratitis

Mild exposure keratitis is frequently noted for the first few weeks after surgery. This seems to cause little or no problem in children, since the epithelium soon heals and the patient readjusts to the new situation. In adults, corneal staining may persist and be significant. Tear function must be reevaluated. In general, temporary tear replacement, ointments, and lid closure at night produce adequate protection, and the problem disappears. If the problem persists, consider placement of temporary punctal plugs. Significant lagophthalmos is unusual in patients with levator dehiscence, since lid function is simply restored. Some lagophthalmos is common after frontalis sling procedures and with maximal levator resections. The parents should always be informed preoperatively that the eyes will remain open to some extent while a child is asleep and that temporary protection is necessary.

Corneal abrasion

Corneal abrasion can result from sutures inadvertently placed through the tarsus or conjunctival surface. After suture placement, evert the lid to check that a suture is not exposed. Protect the globe and cornea during dissection and suture placement and, as noted above, especially during Wright needle insertion. Consider using a contact lens corneal protector or lid plate.

Infection and inflammatory reactions

Infection is extremely rare following levator surgery. It may occasionally occur with frontalis sling procedures, since an avascular, possibly foreign material is introduced. In addition, a noninfectious inflammatory reaction to implanted materials may occur. Chances of infection may be reduced by irrigating the operative site with an antibiotic solution at the end of the procedure. Take great care to avoid introducing cilia or other foreign material into the operative site during placement of the fascia. Treat infections by heat and appropriate systemic antibiotics. If some material other than fascia is placed, its removal may be necessary.

Late granulomatous inflammatory reactions can be observed around suture materials. Once a suture abscess has been excluded, treat these conservatively with warm compresses and antibiotic-steroid combination ointments if superficial, followed by steroid injection at the site, with or without removal of the inciting material and fistulous tract.

Double vision

Usually, postoperative diplopia is due to direct damage to the superior rectus muscle and sometimes the superior oblique muscle; rarely, it is due to direct nerve damage.

 

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