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Year : 1979  |  Volume : 27  |  Issue : 4  |  Page : 137-140

Total transplantation of superior rectus for ptosis (A new surgical technique)

Medical College, Amritsar, India

Correspondence Address:
Daljit Singh
Professor of Ophthalmology, Medical College, Amritsar
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Source of Support: None, Conflict of Interest: None

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How to cite this article:
Singh D, Singh M. Total transplantation of superior rectus for ptosis (A new surgical technique). Indian J Ophthalmol 1979;27:137-40

How to cite this URL:
Singh D, Singh M. Total transplantation of superior rectus for ptosis (A new surgical technique). Indian J Ophthalmol [serial online] 1979 [cited 2021 Oct 19];27:137-40. Available from: https://www.ijo.in/text.asp?1979/27/4/137/32604

Table 1

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Table 1

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Little less than 1/2 of all cases of ptosis are severe in degree with poor levator function. Every one in four cases of ptosis is bilateral. 3/5th of all cases of severe ptosis have very good superior rectus function.

Total transplantation of superior rectus muscle into the lid is ideal for all cases of severe ptosis with poor levator function, but having a normal superior rectus. On the basis of embryological, anatomical and physiological similarities, the superior rectus muscle appears to be the most natural substitute for a defunct levator muscle.

During the last 2½ years, we have operated upon 15 severely ptotic lids by total transplanta­tion of superior rectus muscle. They include 4 bilateral and 7 unilateral cases.

  Material and Methods Top

Steps of operation

  1. The upper lid is everted by Dasmarre's lid retractor and two thick threads are passed through the tarsus, near its upper border. The threads are pulled up so as to fully expose the fornix. Lignocaine with adrenaline is injected under the conjunctiva and under the Muller's muscle, so as to facilitate dissection.
  2. The conjunctiva is cut near the upper edge of the tarsal plate and dissected towards the fornix. Two stitches are passed through the conjunctiva and pulled away [Figure - 1].
  3. The attachment of the Muller's muscle to the upper edge of the tarsal plate is severed and the muscle is reflected upto its origin from the levator muscle. Two stitches are passed through the cut edge of the Muller's muscle. At this stage the crescentric line of insertion of the levator aponeurosis to the orbital septum becomes visible.
  4. A small opening is made in the middle of the Muller's muscle near its origin. A muscle hook is introduced through this opening and the tendon of the superior rectus muscle is brought forwards.
  5. The superior rectus muscle is cleared of the connective tissue covering for a distance of about 20 mm.
  6. Three sutures are passed through the tendon of the superior rectus muscle [Figure - 2]. These are then tied to the orbital septum at the crescentic line [Figure - 3].
  7. The tendon of the superior rectus is then completely severed from the eyeball. The Muller's muscle and the conjunctiva are then stitched back to their original sites.
  8. The lower lid is pulled up with ra stitch and bandage applied.

Postoperative Management

The bandage is opened on the third day. The lower lid stitch is removed. At this time, most patients find difficulty is closing the eye. They are advised to practice forced blinking throughout the day. The operated eye is bandaged at night. Conjunctival stitches are removed after 15 days.

  Results Top

A total of 15 operations have been done during the last 2½ years. Six operations were done from the skin side and the remaining 9 by the conjunctival route. One of them had already undergone unsuccessful levator surgery. 7 cases were unilateral while 4 were bilateral. The results are shown in [Table - 1].

It will be seen that good cosmetic correction [Figure - 4],[Figure - 5] was obtained in 13 eyes and slight under correction in 2 eyes. The move­ments of the operated lids 2 months after surgery were between 12 and 15 mm in 13 eyes. In two eyes the movement was a little less than 10 mm. One patient developed diplopia after the operation. Binking was not abolihsed in any case. One unilateral case developed epithelial keratitis two weeks after operation, which cleared with blinking practice and the use of methylcellulose drops.

Bell's phenomenon: Preoperatively, the movement was upwards in all the cases. In the immediate post operative period, the operated eye generally moved downwards. Later on in unilateral cases the operated eye generally moved up and in. In bilateral cases the eyes moved upwards in 2 cases, remained stationary in one case and moved downwards in one case.

None of the cases showed entropin, ectropion, lid notching, lid lag or lagophthalmos.

  Discussion Top

The use of superior rectus muscle to replace the action of levator palpebrae superioris was introduced by Motais (1897), who inserted strips of the middle fibres of the tendon of this muscle into the anterior face of the tarsus. More than a dozen procedures utilizing superior rectus muscle force have been reported since then.

The rationale of our choice of a free superior rectus muscle (totally served from the eye ball) for transplantation into the lid in cases of severe ptosis lies in the close kinship of levator palpebrae superioris and the superior rectus muscles in great many respects.

The actions of the levator and superior rrectus muscles are almost identical, the differ­ences in the results of their actions are namely due to their different modes of insertion. To us therefore the superior rectus appears to be the most natural choice for elevating the lid in cases of levator muscle failure.

The strong reflex elevation of the operated upper lid on attempted blinking or closure, when encountered in the very first case, caused us much dismay and worry. It was evident that the Bell's phenomenon had been transferred to the lid by the operative procedure. The great adjustability of the nervous system to the changed anatomy was evident by the 5th day, when some improvement in the condition was apparent. By the fifteenth day the patient could easily open or shut the eye without any interference from the Bell's phenomenon. This problem was encountered in every case of the series. The uneasy period of about 10 days was safely passed by observing the elementary precautions of keeping the bandage at night and forced blinking during the day.

Many cases of unilateral severe ptosis have uniocular vision, in the primary position with normal head posture. Some patients manage to obtain binocularity by extreme elevation of the chin; such patients are likely to develop diplopia after total transplantation of the superior rectus. These cases may need addi­tional surgery to overcome annoying diplopia. This may involve the surgery of the contralateral superior rectus or the inferior oblique. In one of our cases, who developed diplopia, cutting of opposite superior rectus muscle abolished it.


  1. Bilateral severe ptosis, i.e. 4 mm or more, with poor levator function.
  2. Unilateral severe ptosis with poor levator function:

    a. With amblyopia of the affected eye.

    b. With good binocular vision: These patients are likely to develop diplopia after operation which may necessitate additional surgery.
  3. Cases where the resection of the levator muscle has failed to give results.
  4. Macrus Gunn ptosis.


  1. Replacement of the defunct levator muscle with a muscle of nearly equal force, direction and innervation.
  2. Preservation of the Muller's muscle in its normal anatomical relationship.
  3. Complete absence of disturbance to the structures of the lid anterior to the orbital septum.
  4. Consistent results.
  5. Cosmetically and functionally superior to all the other methods advocated for cases of severe ptosis.
  6. Absence of lagophthalmos, thus assuring protection to the cornea.
  7. Absence of lid-lag entropion, ectropion and notching of the lid.


1. The occurance of diplopia in some cases of unilateral ptosis which may need additional surgery on the fellow eye.[1]

  References Top

Motais, M., 18%7, Ann. Oculist., 118, 5.  Back to cited text no. 1


  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]

  [Table - 1]


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