Management
Ptosis repair is a challenging and often-debated topic. The patient’s ocular, medical, and surgical history help determine whether surgical repair is appropriate. Specifically, the surgeon should be aware of any history of dry eye, thyroid eye disease, previous eye or eyelid surgery, and periorbital trauma.
Ptosis that causes amblyopia, significant superior visual field loss, or difficulty with reading is considered to be a functional problem. In other instances, ptosis may be considered a cosmetic issue. Because ptosis repair is often an elective surgical procedure, it is particularly important for the surgeon to review the cosmetic and functional consequences of the procedure as well as potential risks.
Ptosis repair surgery should be directed toward correction of the underlying pathologic condition. The 3 categories of surgical procedures most commonly used in ptosis repair are
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external (transcutaneous) levator advancement
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internal (transconjunctival) levator/tarsus/Müller muscle resection approaches
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frontalis muscle suspensions
The amount and type of ptosis and the degree of levator function are the most common determining factors in selecting the type of corrective surgery. Other important considerations are the surgeon’s experience and comfort level with various procedures. In patients with good levator function, surgical correction is generally directed toward the levator aponeurosis. However, if levator function is poor or absent, frontalis muscle suspension techniques are preferred.
External (transcutaneous) levator advancement surgery is most commonly used when levator function is normal and the upper eyelid crease is high (Video 12-5). In these patients, the levator muscle itself is normal, but the levator aponeurosis is stretched or disinserted, thus requiring advancement (Fig 12-18). The levator aponeurosis is approached externally through an upper eyelid crease incision and is advanced to the superior tarsal border. The patient’s cooperation is elicited to open the eyelids to obtain optimal height and contour.
VIDEO 12-5 External levator advancement ptosis repair.
Courtesy of Jill Foster, MD; Dan Straka, MD; and Craig Czyz, DO.
The internal (transconjunctival) approach to ptosis repair is directed toward the Müller muscle, the tarsus, or the levator aponeurosis or muscle (Video 12-6). A comparison of MRD1 before and after the instillation of 2.5% phenylephrine may be performed to identify patients who are candidates for the internal approach (Fig 12-19A, B). The Müller muscle–conjunctival resection procedure (MMCR) was traditionally used for repair of minimal ptosis (2 mm or less). However, recent evidence supports its use in cases of severe ptosis. The procedure is generally considered useful for maintaining the preoperative eyelid contour. The Fasanella-Servat ptosis repair procedure, which is used for small amounts of ptosis, includes removal of the superior tarsus with the conjunctiva and Müller muscle.
VIDEO 12-6 Müller muscle–conjunctival resection.
Courtesy of Jill Foster, MD; Dan Straka, MD; and Craig Czyz, DO.
Many patients with significant ptosis use the frontalis muscle in an attempt to raise the eyelid and clear the visual axis. In frontalis suspension surgery (Fig 12-20), which is performed when levator function is poor or absent, the eyelid is suspended directly from the frontalis muscle so that movement of the brow is efficiently transmitted to the eyelid. Thus, the patient is able to elevate the eyelid by using the frontalis muscle to lift the brow. Several sling options exist for frontalis suspension; they can be grouped as autogenous, allogenic, or synthetic.
Autogenous tensor fascia lata has shown good long-term results but requires the patient to undergo additional surgery related to tissue harvesting. Generally, autogenous fascia lata can be used in patients who are at least 3 years old or weigh 35 pounds or more. Alternatively, the frontalis muscle can be advanced inferiorly to the eyelid as a flap for eyelid elevation.
Allogenic slings include banked fascia lata, which can be obtained from a variety of sources and spares the patient from harvesting surgery. However, this material may incite inflammation and has the theoretical potential to transmit infectious disease.
Synthetic materials such as silicone rods are commonly used. No tissue harvesting is involved, and this option allows for easier adjustment or removal if necessary.
There is some controversy about whether bilateral frontalis suspension should be performed in patients with unilateral congenital ptosis. A bilateral procedure may improve the patient’s symmetry and stimulate the need to utilize the frontalis muscle to lift the eyelids, but it subjects the normal eyelid to surgical risks. The decision of whether to modify a normal eyelid in an attempt to gain symmetry must be discussed by the surgeon and the patient or the patient’s caregiver.
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Lee MJ, Oh JY, Choung HK, Kim NJ, Sung MS, Khwarg SI. Frontalis sling operation using silicone rod compared with preserved fascia lata for congenital ptosis a three-year follow-up study. Ophthalmology. 2009;116(1):123–129.
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Patel RM, Aakalu VK, Setabutr P, Putterman AM. Efficacy of Muller’s muscle and conjunctival resection with or without tarsectomy for the treatment of severe involutional blepharoptosis. Ophthalmic Plast Reconstr Surg. 2017;33(4):273–278.
Complications
Undercorrection is the most common complication of ptosis repair. Astute judgment is required to differentiate this from a mechanical ptosis caused by early postoperative edema. Other potential complications include overcorrection, unsatisfactory eyelid contour, scarring, wound dehiscence, eyelid crease asymmetry, conjunctival prolapse, tarsal eversion, implant extrusion, and lagophthalmos with exposure keratopathy. This latter condition is usually temporary, but it requires treatment with lubricating drops or ointments until it resolves. Achieving symmetry between the 2 eyelids is a difficult aspect of ptosis repair, and some ptosis surgeons use adjustable suture techniques or early adjustment in the office during the first 2 postoperative weeks when indicated.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.