|Year : 1987 | Volume
| Issue : 3 | Page : 132-135
Levator surgery in post traumatic ptosis
SM Betharia, Sushil Kumar
Dr. RP. Centre for Ophthalmic Sciences, ALL.S, Ansari Nagar, New Delhi-110 029, India
S M Betharia
Dr. RP. Centre for Ophthalmic Sciences, ALL.S, Ansari Nagar, New Delhi-110 029
Source of Support: None, Conflict of Interest: None
The results of levator resection in a large series of traumatic ptosis are reported. The various important points in the assessment of a case of traumatic ptosis alongwith the problems in the surgery are highlighted. The skin approach levator resection was the method of choice in these cases The guidelines regarding the amount of levator resection and the placement of the lid margin in relation to the limbus on the operation table are given. Overcorrection does not seem to be a major problem if the average waiting period before the surgery is of 6 months duration. It is better to err on an overcorrection side as recessing the levator is easier than resection of levator for under correction.
|How to cite this article:|
Betharia S M, Kumar S. Levator surgery in post traumatic ptosis. Indian J Ophthalmol 1987;35:132-5
| Introduction|| |
In the present era of automobile accidents the incidence of traumatic ptosis has increased considerably. It is now seen quite frequently in clinical practice and still remains a challenging problems as regards its management The injury to the lid structures may be due to indirect blunt trauma or due to traumatic lacerations The levator muscle may be injured directly or its nerve supply may be damaged Acute lacerations of the lid are often associated with concomitant injuries that may have priority in the treatment especially when the life of the patient is in danger. During the immediate surgical intervention the damage to the levator may-be masked by the severe lid oedema and sometimes the levator may not be properly sutured back onto the tarsal plate, thereby resulting in traumatic ptosis. In the treatment of such cases various surgical procedures employed are Fasanella-Sarvat operation, levator resection and suspension procedures depending upon the levator function Regarding levator resection there are no clearcut guidelines in the literature. The purpose of this communication is to present the results of levator resection by skin approach in a large series of traumatic ptosis with different levator functions and to give some guidelines regarding the amount of levator to be resected and positioning of lid margin in relation to the limbus.
| Materials and Methods|| |
15 cases of traumatic ptosis were operated by skin approach levator surgery. The cases of the post traumatic ptosis and the clinical presentations of the cases are given in [Table - 1].
Preoperative assessment included the measurement of levator action, amount of ptosis, assessment of Bell's phenomenon and associated lid deformities like lid notches, entropion, ectropion, adhesions between levator and globe. The presence of lid fold, hypotropia and muscle imbalance were also noted The corneal sensations were tested The visual acuity and the status of lacrimal secretory system were carefully recorded Lids were also examined for the presence of any foreign bodies The preoperative photographs in three gazes were taken The amount of ptosis varied from 3 to 5 mm and the levator action ranged from 3 to 8 mm. The skin approach levator resection was carried out in all cases after waiting for an average period of 6 months
| Surgical steps|| |
Under general anasthesia the incision was given at the proposed site of the lid fold. The orbital septum was carefully identified and cut to herniate the pad of fat Three stay sutures of white cotton thread were passed through the levator and the lid was everted on the spatula The conjunctiva just above the tarsal plate was ballooned out with xylocaine to facilitate the separation of levator from the conjunctiva and Muller's muscle The levator was then disinserted from the upper border of the tarsal plate The lateral and the medial horns were cut avoiding injury to the lacrimal gland and the reflected part of the superior oblique tendon. The fibrosis present in these cases caused bleeding. The simple pressure haemostasis was done The use of cautery was avoided. The fibrous bands near the orbital septum were excised and the levator was made absolutely free of all adhesions The requisite amount of levator was resected so that the position of the lid margin remained at the limbus or covering 1.5 mms of the limbus depending on the levator action and the amount of ptosis The modified Frost suture was finally given in all cases
| Observations & Results|| |
Postoperatively the cases were followed up for6 to 18 months with an average period of 9 months The cases were carefully assessed for-the amount of correction, any tenting or notching of the lid, Bell's phenomenon, lagophthalmos and comeal changes for exposure keratitis The details of the results and complications are shown in [Table - 2]
| Discussion|| |
Traumatic ptosis is commonly seen after deep lid lacerations or avulsions which need exploration, tissue identification and suturing of the injured tissues in layers However it can result after removal of dermolipoma,  orbital surgery, enucleation and while taking graft from the upper fornix of conjunctiva due to inadvertent damage to the Muller's muscle In these cases 6 months of minimal waiting period is recommended  These cases were reported to go into overcorrection more often following levator surgery as compared to the cases of congenital ptosis , Peter Ballen  has suggested levator resection if levator action is more than 5 mm. The levator resection by skin approach was carried out as it offered obvious advantages such as ease of anatomical orientation and dissection, identification of levator, excision of fibrous bands especially near the area of orbital septum and better mobility of the levator after cutting both the horns of the muscle. Certain common problems seen on the operation table were excessive bleeding because of fibrosis, button holing of conjunctiva, difficulty in identification of levator and its proper mobilization, lid notching, specially on the medial side of the lid margin and entropion resulting from excessive resection of the posterior laminar lid tissues
Excessive bleeding was controlled by ligating the bleeders and by pressure haemostasis Cautery should not be used as it leads to further fibrosis The levator can be identified once the orbital septum was located and after herniation of the pad of fat The button holing of conjunctiva was avoided by injecting xylocaine underneath the conjunctiva so as to have a plane of cleavage between levator and conjunctiva - Muller's muscle complex The muscle was made absolutely free after cutting both the horns and excising the fibrous adhesions especially near the area of orbital septum. The lid notching was avoided by equidistant placement of catgut sutures on the tarsal plate and tying the knots with equal pressure The knot on the medial side was tied gently as we had observed a greater tendency for notching on the medial side The entropion was avoided by limiting the amount of resection to not more than 18 mm.
There seems to be a usual belief that every case of traumatic ptosis is likely to go in for over correction and so a more conservative surgery is called for. This we find is really not true if there is a minimum waiting period of 6 months before the operation and subsequently levator action and the amount of ptosis is assessed properly. In our cases the lid margin was positioned in relation to the limbus during surgery according to the levator function as given in [Table - 3].
We found that comparatively lower amount of levator resection was needed in these cases as compared to congenital ptosis The usual amount resected varied from 14 to 18 mm. However, Berke  is of the opinion that it is better to err on the overcorrection side rather than undercorrection as recessing the levator is easier than resecting the muscle for the second time.
In the postoperative follow up of all these cases the points noted apart from the correction of ptosis were lagophthalmos, lid lag, entropion, any signs of overcorrection, establishment of normal Bell's phenomenon and exposure keratitis The lid lag was likely to be more if the fibrous bands at the orbital septum area were not excised The lagophthalmos is likely to be more than 18 mm of levator is excised and similarly this might also cause entropion due to posterior laminar shortening The exposure keratitis could result because of gross overcorrection and lagophthalmos and sometimes by delayed establishment of Bell's phenomenon or inversion of Bell's phenomenon as described earlier by Betharia et a1 . The inverted Frost suture should never be removed unless the Bell's phenomenon has fully seen established and the cornea is fully protected.
| References|| |
Paris, QL and Beard, C 1973, Ann. Ophthalmol, 5:697
Beard, C and Sullivan, J.R, 1979, Traumatic ptosis 'Ocular Trauma' edL by Freeman HM AppletionCenturyyCrofts, New York, 85
Smith, S and Obear, M, 1967, Surg. Clin. N. Am, 47:515
Ballen, P., 1981, Third International Symposium of Plastic and Reconstructive Surgery of the Eye and Adnexa Williams and Wilkins, Baltimore/London, 269
Berke, RN. 1971, Amer. J. OphthalmoL, 72: 691
Betharia S.M and Kalra, BR, 1985. Ind J. Ophthalmol, 33:109
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
[Table - 1], [Table - 2], [Table - 3]