Kalin-Hajdu, Evan; Wang, Qinyun; McLeod, Stephen D.; Vagefi, M. Reza
A 71-year-old Caucasian woman presented 2 weeks following bilateral internal levator resection and upper and lower blepharoplasty. A higher than desired left upper lid was noted for which downward massage was instructed. At postoperative week 6, the patient presented with best-corrected visual acuity (VA) in the left eye (OS) of 20/100 down from pre- and immediate postoperative VA of 20/40. Retinoscopy revealed superior irregular astigmatism OS confirmed on corneal topography that was not present on prior studies (Fig. A). Lid massage was stopped, and at postoperative month 3, VA OS improved to 20/50 with normalization of topography consistent with corneal warpage (Fig. B). This is the first report of corneal warpage due to aggressive lid massage, to the best of our knowledge. As with contact lens wear, the changes appear to be reversible.
Rubinstein, Tal, J., M.D.; Repp, Daniel, J., M.D.; Sires, Bryan, S., M.D., Ph.D., F.A.C.S.
Purpose: To investigate the effects of performing a previously described algorithmic levator resection for involutional ptosis with a blepharoplasty instead of through a small incision.
Methods: Eyelids with involutional ptosis and normal levator function were included in the study. An upper blepharoplasty was performed first. An external levator resection was then performed based on a described technique involving 2 mm resection of aponeurosis for 1 mm of desired lift, consistent tension on the aponeurosis between surgical cases, and standardized suture placement.
Results: Forty-one eyelids of 25 patients were included. Mean postoperative margin to reflex distance 1 (MRD1) was 2.98 mm, which was significantly higher than preoperative MRD1 (0.67 mm), but lower than the predetermined goal MRD1 (3.35 mm). Eight eyelids did not meet primary outcome of MRD1 within 1 mm of goal MRD1, with 5 undercorrections. There was no difference between the postoperative MRD1 compared with the same ptosis technique performed through a small incision only, but there were more intraoperative suture adjustments and fewer eyelids meeting the primary outcome when a concurrent blepharoplasty was performed.
Conclusions: The addition of blepharoplasty with a previously described algorithmic approach external levator resection has an 80% success rate in achieving the primary outcome. When compared with a small-incision ptosis repair, concurrent blepharoplasty results in a less predictable outcome and an increased need for intraoperative adjustment. Performing an algorithmic technique for external levator resection with a blepharoplasty has less predictable outcomes, which raises the question of separating the procedures to improve patient care.
Ju-Hyang Lee, Yoon-Duck Kim
Unilateral congenital ptosis with poor levator function of ≤4 mm continues to be a difficult challenge for the oculoplastic surgeon. Surgical correction can be accomplished with unilateral frontalis suspension, maximal levator resection, or bilateral frontalis suspension with or without levator muscle excision of the normal eyelid. Bilateral frontalis suspension was proposed by Beard and Callahan to overcome the challenge of postoperative asymmetry, allowing symmetrical lagophthalmos on downgaze, postoperatively. However, most surgeons and patients prefer unilateral correction on the abnormal eyelid either with a frontalis suspension or maximal levator resection. Frontalis suspension may be performed through the various surgical techniques using different autogenous or exogenous materials. Autogenous fascia lata is considered the material of choice with low recurrence rates but carries the drawbacks of the difficulty of harvesting and postoperative morbidity from the second surgical site. Recent reports have suggested that maximal levator resection provides improved cosmesis, a more natural contour, and avoids brow scars. Although both treatments have shown to have similar success rates, there is much debate about what the most favorable method for treating severe unilateral ptosis. We review the literature on the various surgical treatments for unilateral severe congenital ptosis, including the rationale, advantages and disadvantages of each technique.
Ju-Wen Yang, MD
The traditional technique for levator muscle resection includes a time-consuming dissection procedure that causes tissue trauma and swelling. The Putterman ptosis clamp has been popularly used in recent years for conjunctival müllerectomy. In this paper, we describe a modified surgical technique for ptosis treatment using the Putterman ptosis clamp. The modified technique improves the surgical results of levator muscle resection.
We performed a retrospective case-series study to determine the outcomes and complications associated with the use of the Putterman ptosis clamp in levator muscle resection.
Adults aged ≥18 years with moderate-to-severe ptosis underwent the modified technique for levator muscle resection. We first performed dissection to expose the aponeurosis and tarsus. Then, we placed the Putterman ptosis clamp to measure redundant aponeurotic and septal tissues and to perform the resection. Following the adjustment of the eyelid fissure, we refixed the levator muscle to the tarsus with 4-0 vicryl stitches.
Seventeen patients (34 eyes) were included in the study. Of the 34 eyes, 31 (91.2%) experienced the complete resolution of ptosis after the surgery. One patient (2 eyes, 5.9%) had mild bilateral dermatochalasis and received revision surgery 6 months postoperative. One patient (1 eye, 2.9%) lost the crease of the left eye and received revision surgeries 2 and 6 months after the first surgery. No residual ptosis or severe adverse events were noted in the patients.
Modified levator muscle resection using the Putterman ptosis clamp is an effective procedure for ptosis treatment.
Francesco M. Quaranta-Leoni, Sabrina Sposato, Antonella Leonardi, Licia Iacoviello & Simona Costanzo
The authors analyzed the cosmetic and functional results of a series of patients with unilateral congenital ptosis who underwent levator resection, to compare the outcome of surgery according to the age of intervention, and to evaluate the chance of ptosis recurrence in different age groups. Analysis of the clinical charts of 44 patients who underwent a unilateral levator muscle resection under the care of one surgeon from February 2000 to March 2012 was performed. Age at the time of surgery ranged from 2.1 to 12 years. The study population was divided into different groups according to the age of surgery. Preoperative evaluation included measurements of upper eyelid margin reflex distance (MRD1), levator function, frontalis function, and complete extraocular motility examination. This study adheres to the principles outlined in the Declaration of Helsinki. The patients’ follow-up ranged between 2 and 12 years. The outcome of surgery was more satisfactory (MRD1 increase: p < 0.002) and the increase of levator function was better (p < 0.0001) when surgery was performed in children aged 2 to 4 years. No ptosis recurrence was observed in children aged 2 to 4 years, as opposed to 6 (22%) children of other groups (p = 0.067). Unilateral levator resection effectively reduces the asymmetry between eyelids. The age of the operation appears to influence the outcome of surgery, as in this series cosmetic and functional results are better and the rate of ptosis recurrence is lower if the child is operated on before the age of 4 years.
Chinh T. Nguyen & Thomas G. Hardy
The aim of this study was to determine whether pre-operative levator function and degree of ptosis affect surgical outcomes in children with congenital ptosis undergoing anterior levator resection under general anaesthesia. Retrospective cohort study. Children with ‘simple’ congenital ptosis who underwent anterior levator resection under general anaesthesia. Consecutive cases were reviewed with regards to achievement of the desired lid height (surgical success), and the influence of preoperative levator function and degree of ptosis. The amount of pre-operative levator function and degree of ptosis, with corresponding surgical outcomes. Forty-two lids (37 patients) were included in the study: 36 primary and 6 revision cases (which were excluded from analysis due to small sample size). Mean age was 7 years (range 3–17 years), with similar male to female ratio (1.2:1). The overall success rate for primary was 86%. There were small to moderate trends towards greater amount of levator resection for lower levator function (r2 = -0.25, p < 0.05) and higher degree of ptosis (r2 = 0.38, p < 0.05). All successful primary cases (n = 31) had pre-operative levator function of at least 8 mm. Levator resection in children under general anaesthesia continues to be an imprecise science. Degree of ptosis and levator function were poorly correlated to each other; however, there was an expected small to moderate correlation between resection amount and levator function (negative correlation) or degree of ptosis (positive correlation). Patients with levator function of 8mm or more are likely to have a successful outcome.
Özlem Ural, MD; Mehmet C. Mocan, MD; Ugur Erdener, MD
To evaluate the therapeutic benefits of frontalis suspension as a repeat intervention in congenital blepharoptosis.
METHODS:Pediatric patients diagnosed as having congenital ptosis who had at least 2 years of postoperative follow-up were included in this retrospective study. A successful outcome was defined as a postoperative margin-reflex distance of 3 mm or greater. The chi-square, Student’s t, and Mann–Whitney U tests were used in comparisons.
RESULTS:Eighty-four eyes of 77 patients with a follow-up period of 8.4 ± 0.7 years were included. The initial surgery was levator resection in 29 (34.5%) eyes and frontalis suspension in 55 (65.5%) eyes. Frontalis suspension was performed for all repeat interventions (n = 20). Surgical success was achieved in 61.9% of patients with single surgery (75.9% for levator resection vs 54.5% for frontalis suspension; P= .06) and in 77.4% of patients following repeated surgeries (93.1% vs 69.1% for patients who initially underwent levator resection vs frontalis suspension, respectively; P = .012). A higher success rate was associated with better preoperative levator function (P = .01) and a higher margin-reflex distance (P = .004), and was inversely proportional to ptosis severity (P = .04).
Frontalis suspension as a repeat intervention for congenital blepharoptosis is associated with a further increase in long-term anatomic success rates and should be considered when initial procedures fail or remain inadequate.
Ju-Hyang Lee, Orapan Aryasit, Yoon-Duck Kim, Kyung In Woo, Llewellyn Lee, Owen N Johnson
Background/aims Surgical treatments for the correction of congenital ptosis with poor levator function, including frontalis suspension or maximal levator resection, remain controversial. We evaluated the postoperative surgical and cosmetic outcomes after maximal levator resection for unilateral congenital ptosis with poor levator function.
Methods A retrospective, interventional case series was performed. A total of 243 patients with 243 eyelids (210 unilateral and 33 bilateral asymmetric ptosis) who underwent unilateral maximal levator resection were included. The surgical results were graded as excellent, good and poor and postoperative complications were documented.
Results The mean age at the time of surgery was 8.8±9.7 years (range, 2–58 years) with mean follow-up time of 40.9±38.9 months (range, 3 months to 18.9 years). Satisfactory results (excellent or good result) were obtained in 93.0% of the patients. Patients were divided into two groups based on levator function as follows: 0–2 mm (80 cases) and 2.5–4.0 mm (163 cases). Factors such as preoperative levator function, margin reflex distance-1 and levator dehiscence were not correlated with postoperative surgical outcomes. Complications included exposure keratopathy (11.1%), lid crease asymmetry (8.2%), entropion (8.2%), overcorrection (3.3%), eyelash ptosis (3.7%), temporal eyelid droop (3.3%), suture abscess (0.8%) and conjunctival prolapse (0.8%).
Conclusions Maximal levator resection is an effective procedure for congenital ptosis even in patients with poor levator function, which provides improved cosmesis, a more natural lid contour, and avoids brow scars.
Kenichi Kokubo, Nobutada Katori, Kengo Hayashi, Jun Sugawara, Akiko Fujii, Jiro Maegawa
Although we commonly observe eyebrow drooping during and after blepharoptosis surgery, it may not occur in some cases. After levator resection was performed in 47 patients (84 eyelids) with blepharoptosis, the eyebrow heights at the medial canthus, the center of the pupil, and the lateral canthus were measured using scanned photographs obtained preoperatively and 3 months postoperatively. In the 84 eyelids, after levator resection, the eyebrow position was lowered at the medial canthus in 76 patients (90%), at the center of the pupil in 75 (89%), and at the lateral canthus in 76 (90%). The mean distance of eyebrow drooping in the 84 pupils was 2.74 mm at the medial canthus, 2.91 mm at the center of the pupil, and 2.58 mm at the lateral canthus. In addition, there was a significant difference between the extra skin excision group and the no skin excision group at the medial canthus (p = 0.027), the center of the pupil (p = 0.001), and the lateral canthus (p < 0.001) (Mann–Whitney test). Unfortunately, there was a significant difference in ages between the extra skin excision group and the no skin excision group. In conclusion, eyebrow drooping was caused after levator resection in most cases. However, it is difficult to anticipate eyebrow drooping distance before surgery.