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Year : 1973  |  Volume : 21  |  Issue : 3  |  Page : 95-97

Levator resection in ptosis. How much and how?


Department of Ophthalmology, Medical College, Amritsar, India

Correspondence Address:
M S Nirankari
Department of Ophthalmology, Medical College, Amritsar
India
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Source of Support: None, Conflict of Interest: None


PMID: 4500009

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How to cite this article:
Nirankari M S, Khanna K K, Gupta M G, Singh M. Levator resection in ptosis. How much and how?. Indian J Ophthalmol 1973;21:95-7

How to cite this URL:
Nirankari M S, Khanna K K, Gupta M G, Singh M. Levator resection in ptosis. How much and how?. Indian J Ophthalmol [serial online] 1973 [cited 2021 May 8];21:95-7. Available from: https://www.ijo.in/text.asp?1973/21/3/95/31390

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It is generally agreed that resection of levator palpebrae superioris (LPS) is the most physiological approach to the treatment of a ptosis case. Though BOWMAN [2] was credited to be the pioneer in advocating the shortening of L.P.S. through conjunctiva, it was BLASCOVICS [1] who popularised this technique of shortening and advance­ment of L.P.S. through conjunctiva. Many modifications of Blascovics' technique have been put forth by various surgeons but the original technique still holds the field. EVERSBUSCH [3] devised an operation for shortening the L.P.S. through skin approach. This technique (Everbusch operation) too has many exponents.

There is also difference of opinion regarding the amount of levator resection to be done for a given case of ptosis. This paper presents a new formula for quantitative assessment of L.P.S. resection required in a given case of ptosis. An attempt has been made to comparatively evaluate the results of L.P.S. resection through a conjunctival and a skin approach.


  Material and Methods Top


Thirty cases of uncomplicated unilateral congenital ptosis were taken up for this study. Besides the general and local examination, the amount of ptosis and the amount of L.P.S. function were accurately measured in each case. The amount of ptosis was assessed by measuring the difference of the width of the palpebral fissure on two sides in the pupillary region and also measuring the difference in the distance from the mid point of the eyebrow to the margin of the upper lid in primary position of gaze.

The amount of retained L.P.S. function was measured by measuring the excursion of lid from down to up gaze after immobilizing the frontalis with firm pressure by thumb on the brow. Elevation of lid by more than 7 mm was considered as good L.P.S. action while 4 to 6 mm was termed as fair and less than 4 mm as poor.

All cases were operated under general anaesthesia. Fifteen cases were operated by trans-cutaneous and 15 cases by transconjunctival approach.

Follow Up - Besides noting the operative and post-operative compli­cations each case was followed for six months. The final results were compiled as under:

Good - Full correction of ptosis, well formed lid fold and no cosmetic blemish.

Satisfactory - Full correction of ptosis, lid folds not well formed but no other complications.

Failure - Under or overcorrection of ptosis or any other cosmetic blemish like lagophthalmos, notching of lid border, with or without improper lid folds.

Before contemplating surgery, the amount of resection to be done was decided in each case by the following formula:­

(A) In the cases with good LPS action - 3 mm. resection of levator or 1 mm. of ptosis plus 5 mm. to make up for the minimum of 8 mm. resection.

(B) In the cases with fair LPS action - 4 mm. resection of levator for each 1 mm. of ptosis plus 4 mm. to make up for the minimum of 8 mm. resection.


  Discussion Top


Resection of LPS is the most physiological approach to the treat­ment of ptosis. About 70% to 80% ptosis repairs are done by this technique. This is the operation of choice in all cases with fair to good (more than 4 mm.) levator function.

According to Dayai [4] it is difficult to assess the amount of levator resection to be done and final results of the surgery. Many factors like skill of the operator, extent of exposure, quality of muscle and its action and amount of ptosis, determine the final out-come in a given case. We agree with him that these factors do play a role in ptosis correction, but at the same time we think that it is possible to assess the amount of levator resection to be done in a given case.

We consider the ptotic lid to be a weight and the LPS muscle a band to lift it up. A thin rubber band would have to be shortened more than a thick one in order to lift a given weight. So in deciding the amount of resection to be done two factors, i.e., the amount of ptosis (weight factor) and the LPS function (rubber band factor) should be taken into considera­tion. From above, it is obvious that the general rule of thumb "3 mm. resection for 1 mm. ptosis" cannot hold good under all circumstances. It is also known that a LPS resection less than 8 mm. does not result in any elevation of the ptoic lid. This further complicates the matters. Taking into account these 3 factors, i.e., amount of ptosis, retained L.P.S. action and basic 8 mm. resection, we have adopted the following formulae to decide the amount of resection required in a given case of ptosis:

(A) In cases with good levator function, resection should be 3 mm. for 1 mm. of ptosis with basic addi­tion of 5 mm. to make up for the minimum of 8 mm. resection. For example, 1 mm. of ptosis would require 3 mm. plus 5 mm. = 8 mm.; 2 mm. of ptosis requires 6 mm. plus 5 mm. = 11 mm. of resection and so on.

(B) In the cases with fair LPS function, resection should be 4 mm. for 1 mm. of ptosis with the basic addition of 4 mm. to make up for the 8 mm. of minimum resection.

To achieve good results, it is imperative to decide beforehand the amount of LPS resection to be done in a given ptosis case. We attribute a high rate of success (87% in this series and 73% in Dayal's series) to the accurate pre-operative assessment in each case.

13% failure in this series, is not because of a wrong or a faulty assess­ment provided by our formulae but because of either early slipping of the sutures or a faulty exposure mobiliza­tion of the LPS muscle.

We agree with Dayal [4] that in cases requiring larger (more than 20 mm.) resection of levator transcutaneous approach produced better results.


  Summary Top


Thirty cases of uncomplicated unilateral ptosis have been studied. A new formula for quantitative assess­ment of amount of L.P.S. resection required in a given case of ptosis has been described. Merits of skin versus conjunctival approach and vice versa for levator surgery has been discussed.

 
  References Top

1.
Blaskovics, L.: A new operation for ptosis with shortening of levator and Tarsus. Arch. Ophthal. 52: 563, 1923.  Back to cited text no. 1
    
2.
Bowman, W. P. quoted by Beard, C.: Ptosised. I, C. V. Mosby Company, Saint Louis, 1969.  Back to cited text no. 2
    
3.
Everbusch, O.: On Operation for Congenital blepharaptosis (in German) Klin. Mbl. Augenheilk, 21: 100, 1883.  Back to cited text no. 3
    
4.
Dayal Y.: Levator Surgery for Ptosis. Proc. All India Ophth: Soc., XXIV, 296, 1967.  Back to cited text no. 4
    



 
 
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