New three-step technique for assessing eyelid height in patients under general anesthesia for ptosis surgery

When blepharoptosis is performed under local anesthesia, it is easy to assess the eyelid height during surgery by observing the eyelid position relative to the superior limbus and the contralateral eyelid position when the patient is sitting. When the patient is under general anesthesia, assessment of eyelid position is more challenging because the patient's cooperation is absent, while at the same time anesthetic agents and local epinephrine may influence the eyelid height.

In a recent issue of Plastic and Reconstructive Surgery, Clinton D. McCord, MD, Hisham Seify, MD, and Mark A Codner, MD, suggest an approach to evaluate the eyelid height in patients with bilateral ptosis undergoing surgery under general anesthesia. They usually use a single central (corresponding to the pupil) double arm suture. They place the suture through the upper tarsus and the levator aponeurosis and tighten it until a symmetrical appearance is obtained by measuring the interpalpebral fissure with a caliper. To ascertain symmetric suture tension, the tension is assessed by pulling the eyelid down by the eyelashes and releasing it. The velocity of the eyelid opening should be equal in both sides (spring back test). Only after symmetry is thus obtained, the skin is approximated by another suture. Performing these steps allowed achieving symmetry in 85 of 64 patients with bilateral ptosis and 16 patients with unilateral ptosis. Only two (2.5 percent) patients required surgical revision.

The steps the authors suggested are simple to adopt in everyday practice though most of the ptosis patients undergo surgery with local anesthesia. Candidates for general anesthesia include children with congenital ptosis and uncooperative patients, communication disabilities (deafness or language barrier) and epilepsy. Other measures to obtain postoperative symmetrical eyelid aperture include adjustable sutures and postoperative evaluation.