|Year : 1983 | Volume
| Issue : 4 | Page : 343-345
Surgical management of residual ptosis
SM Betharia, Y Dayal, B Ghosh
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, A.I.I.M.S., New Delhi, India
S M Betharia
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi-110029
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Betharia S M, Dayal Y, Ghosh B. Surgical management of residual ptosis. Indian J Ophthalmol 1983;31:343-5
Congenital ptosis is a common condition encountered by ophthalmologists all over. A good ptosis correction no doubt is very satisfying to the patient and also a morale booster for the surgeon. However, the cases of residual ptosis pose a great challenge for the surgical management. The purpose of this communication is to highlight our experiences in 30 such cases seen at Dr. R.P.Centre for Ophthalmic Sciences with emphasis on the preoperative assessment and the difficulties encountered in the surgical steps for their management.
| Materials and methods|| |
30 eyes of 14 males and 16 females were operated upon. 26 cases fell in the age group of 11 to 30 years. 14 cases had undergone a conjunctival approach L.P.S. resection, 8 cases had previous sling operation, 7 cases had previous L.P.S. resection by skin approach and 1 case had utilization of superior rectus. 3 patients had 2 previous surgeries each. We have utilized levator resection by skin approach in 25 cases. In 3 cases a simple lid fold formation was done while in 2 cases Fasanella servat operation was done. Preoperative assessment was made mainly regarding the amount of ptosis, the L.P.S. action, the presence and position of lid fold, the extent of Bell's phenomenon and any associated muscle imbalance. Besides this the presence of lid notching, entropion, ectropion, loss of cilia, puckering of skin, blepharochalasis, scars on skin or conjunctival sides and the corneal sensations were noted. All patients had preoperative photographs in looking up, down and straight ahead position for subsequent comparison after surgery.
| Operative steps|| |
I. Levator resection through skin approach ; The site of skin incision was marked with gentian violet at the proposed site of the lid fold. After supporting the lid on the lid spatula dissection of skin and orbicularies was done and the leavator was exposed. The orbital septum area was carefully explored and the septum was incised so that the pad of fat buldged out. Lower down the dissection was carried to expose the upper border of the tarsal plate. Three white thread sutures were passed through the levator muscle asstay sutures. Conjunctiva was ballooned out with xylocaine 2°% solution to facilitate the separation of conjunctiva-Muller's muscle complex from the levator muscle. After careful separation of the levator the medial and lateral horns of the muscle were cut avoiding the damage to superior oblique tendon and lacrimal gland. The presence of adhesions or bands near the orbital septum area which are common in residual ptosis are incised. The sling was undone if any. The measured amount L.P.S. resection was done by passing 50' chromic catgut double arm sutures from the upper border of tarsal plate and through the L.P.S. The position of the lid margin was carefully assessed before giving the final tie to the knots. The lid fold was then formed and the inverted Frost suture was given after repositing the fornix with the lid spatula.
11. Technique of lid fold formation : After supporting the lid on the spatula the incision is placed on the proposed site of the lid fold. The loose skin if any is excised by pinch technique from the upper flap. The 4 0' black silk sutures are passed through the skin orbicularies edge taking a deep bite of the tarsal plate and levator and then a bite from the skin and orbicularis is taken. Thus the unequal pressure forms the lid fold.
III. Fasanella Servat Operation : This was done by the use of white cotton sutures without any curved haemostats so that the desired amount of the tarsal plate can be excised. Atleast 4 mm of tarsal plate or equal to double the amount of ptosis was excised after marking with gentian violet. The continuous suture was given by 6 0' plain catgut with knots burried under conjunctiva at each end.
| Discussion|| |
The undercorrection of ptosis is commonly seen in operated congenital ptosis cases. The causes of the under correction can be numerous. The important ones include inadequate preoperative assessment of L.P.S. action and amount of ptosis, wrong selection of the surgical approach, inadequate dissection of levator, small resections without advancement of levator, not cutting the horns of the muscle and damage to the superior transverse ligament. We feel the most important are the use of conjuctival approach and smaller levator resections. We feel that a minimum of 16 to 18 mm of levator resection should be done in cases of primary surgery even if the levator action is good. The aim should be slightly towards over-correction so that a proper correction results subsequently.
The common complications seen in our cases were lid notches, irregular lifting of the lid, scars on the skin, puckering of the skin, entropion, inadequate or assymetrical lid fold formation.
The moderate to severe cases of residual ptosis were tackled by levator resection by skin approach which has all the advantages like ease of the proper exposure of levator and its dissection, availability of adequate amount of levator muscle for resection after cutting the horns, and proper lid fold formation is possible. This approach is thus most suited for managing residual ptosis cases. The difficulties which we usually come across is excessive bleeding due to the fibrous tissue, dissection of levator and its separation from conjuctiva and Muller's muscle sometimes resulting into buttonholing of conjunctiva and presence of fibrous bands near the area of orbital septum adherent to the levator. The levator should be properly identified and horns must be cut and so also the fibrous bands near the septal area and the muscle is made absolutely free before resection and advancement. The oblique resection of levator was undertaken in cases of irregular droops. A maximum of 16 to 18 mm of levator resection should be done to avoid overcorrection, lid lag and lagophthalmos which are more likely to occur in cases of residual ptosis.
The cases of mild ptosis with faint lid folds were managed by proper lid fold formation. The crux of the good lid fold formation lies in proper marking of the lid fold which should be symmetrical and the depth should be equal to that of the opposite side. The skin edges must be properly undermined and the sutures passed as already described so as to get inversion of the edges.
Fasanella servat operation was done in cases of minimum ptosis with good levator action. The common complication of lid notch was avoided by use of cotton stay sutures allowing the excision of the tarsal plate ;n a graded manner. The corneal abrasion was avoided by using moistened 6.0' plain catgut to make it very soft and by giving a continuous suture with buried knots at each end. To prevent the problem of residual ptosis a judicious and adequate levatior resection by skin approach during primary surgery is called for.
| Summary|| |
Experiences of surgical management of 30 cases of residual ptosis have been highlighted. The common associated problem encountered in these cases were lid notches, irregularity of droop, puckering of the skin, entropion and inadequate and or assymmetrical lid fold. Difficulties in reoperation and the importance of levator resection by skin approach are stressed. The use of Fasanella servatoperaw tion and simple lid fold formation are also discussed.
| References|| |
Dayal. Y. and Crawford, J.S., 1966, Evaluation of results of surgery to correct congenital ptosis of the upper eyelid. Canad. Med. Ass. J. Vol. 94, pg. 1172.
Beard, C., 1981, 'Ptosis' 3rd edi., The C.V. Mosby Company, St. Louis, pg. 240.
Betharia, S.M., Grover, A.K. and Kalra, B.R.e 1983 Brit. J. Ophthalmol. Vol. 67, pg 58.