|Year : 1992 | Volume
| Issue : 3 | Page : 86-89
Blepharoptosis repair by modified sutureless Fasanella-Servat Operation (F.S.O)-A large series of 50 cases
VP Gupta, Rajesh Aggarwal, SP Mathur
Department of Ophthalmology, University College of Medical Sciences and Guru Bahadur Hospital, Shahdara, Delhi-110 095, India
V P Gupta
Department of Ophthalmology, D-7, G.T.B. Hospital Campus, Shahdara, Delhi - 110095
Source of Support: None, Conflict of Interest: None
A modified technique of sutureless Fasanella-Servat Operation (F.S.O.) using special curved haemostat for the correction of mild to moderate acquired ptosis with good Levator Palpebrae Superioris (L.P.S.) action (12 m.m.) was performed in a large series of 50 eyes. Excellent correction was achieved in 94.6% eyes with mild ptosis & 61.6% eyes with moderate ptosis. No operative and post operative complications were observed. The technique was found to be very safe, quick and effective.
|How to cite this article:|
Gupta V P, Aggarwal R, Mathur S P. Blepharoptosis repair by modified sutureless Fasanella-Servat Operation (F.S.O)-A large series of 50 cases. Indian J Ophthalmol 1992;40:86-9
| Introduction|| |
Fasanella & Servat in 1961 introduced a simplified operation for minimal ptosis with good Levator Palpebrae Superioris (L.P.S.) action . This was later popularised by Beard in 1969 & 1970 . Fasanella - Servat Operation (F.S.O.) basically consists of tarso-conjunctival-mullerectomy, followed by suturing of the tarsus and conjunctiva. The original procedure has undergone several modifications in the technique of excision and suturing . Inspite of these modified suturing techniques, occasional severe post operative suture keratitis still remains the main complication. Lauring (1977) reported satisfactory results following his technique of F.S.O. for cases with mild ptosis with good L.P.S. (12 m.m.) action .However reports from other surgeons are not available in the literature.
This study was aimed to describe the modified sutureless F.S.O. and to evaluate its effectiveness in acquired ptosis with good L.P.S. (12 m.m.) action.
| Material and methods|| |
From October 1989 to October 1990, 50 eyes of 35 patients having acquired, mild to moderate ptosis with good L.P.S. action were selected from the out patient department of ophthalmology, University College of Medical Sciences & Guru Teg Bahadur Hospital, Delhi. A detailed history and clinical examination with special emphasis on ptosis measurements and L.P.S. action was done. Routine investigations were done pre-operatively. Informed consent was taken. All the patients were operated by one surgeon (V.P.G.) under local anaesthesia on an out patient basis.
| The technique|| |
Local anesthesia was achieved by instillation of 4% Xylocaine drops and infiltration of 2% Xylocaine in the submuscular plane using a 26 gauge needle. Lid massage was done to evenly spread the anesthetic agent. Three equidistant traction sutures were passed through the upper lid margin using 4-0 ethibond suture. These three sutures were tied together and the upper lid was everted over a lid spatula on the skin side [Figure - 1]. Three equidistant sutures using 4-0 ethibond were passed 1 mm above the superior tarsal margin after marking with gentian violet. A long curved, 4 mm wide haemostatic forceps [Figure - 2] was applied just above the marked line to grasp the tissues of the everted lid (Tarsoconjunctival-muller complex [Figure - 3]. The haemostat was left in place for 60 seconds, after which the haemostat was removed leaving -behind a 4 mm broad ischaemic groove in the tarso-conjunctiva [Figure - 4]. A cut was made in the center of the groove using a sharp scissors, thus excising 3 mm of tarsus [Figure - 5]. Bleeding was minimal as compressed groove above the cut acted as a mechanical suture, however a cotton pad moistened with normal saline was put over the eye with some pressure for 3-5 minutes. The traction sutures at the lid margin were cut. The clots adhering to the cut ends were not removed. No frost suture was used. Antibiotic ointment was put and pressure bandage was given. The surgery was completed within 10 minutes in all cases. All patients were examined 24 hours after operation and periodically thereafter for a minimum period of 3 months. Post-operatively patients were treated with frequent instillation of antibiotic drops and antibiotic ointment at night.
| Results|| |
Out of 35 patients, there were 21 females and 14 male patients. 7 males and 8 females had bilateral involvement. 20 patients (7 males and 13 female) had unilateral mild to moderate acquired ptosis [Table - 1]. [Table - 2] shows the detailed preoperative and post-operative status of all the cases.
The ptosis correction achieved was graded as excellent, good and poor. In excellent correction palpebral aperture of the operated eye is equal to or 1 mm more than the fellow eye in the primary position; in good correction, palpebral aperture is 1 mm less than the fellow eye in primary position but cosmetically acceptable; whereas in poor correction the eyelid remained undercorrected by more than 1 mm, which is cosmetically disfiguring.
In our series of 50, eyes, there were 37 eyes with mild ptosis and 3 eyes with moderate ptosis. 94.6% of mild ptosis cases and 61.6% of moderate ptosis cases had an excellent correction. None of the cases with mild ptosis showed poor result, however 3 eyes (23%) with moderate ptosis showed poor results [Table - 3].
Maximum post-operative correction was achieved within 2 to 3 weeks in 38 eyes (76%), while in 9 eyes (18%) a good correction could be seen even on the third post-operative day. All these 9 eyes had ptosis following cataract extraction.
No operative complications were seen. There were no major post operative complications such as keratitis, granuloma, haemorrhage, infection, lagophthalmos or lid notching. However, mild lid edema was seen in all the cases which disappeared in 7 days. In 5 eyes (10%) mild entropion was noted. A uniformly symmetric lid contour was achieved in all cases except 3 eyes (6%). Foreign body sensation was the most common symptom reported by most of the patients which gradually disappeared at the end of the second week.
| Discussion|| |
Sutureless F.S.O. was devised by Lauring (1977) to overcome the serious complications of suture keratitis following F.S.O. . He suggested that tarsoconjunctival-muIlerectomy done in F.S.O. operation leaves a potential space which is obliterated by the strong pull of the levator muscle, which acts as a natural biological suture .The cut edges of the tarsus and Muller's muscle conjunctiva remain adherent on completion of the resection and levator muscle helps in keeping these cut edges together during the healing period. A good L.P.S. (12 mm) action was the prerequisite for the success of this operation.
In our series of 50 cases excellent correction was achieved in 43 eyes (86%) and good correction in 4 eyes (8%) with an overall success of 94%, however, Lauring reported satisfactory results in 11 out of 12 eyes (91.63%). In our series we have also included cases with moderate ptosis which were not included by Lauring. A perfect symmetry was not achieved in any of his cases however, in our cases a perfect regular symmetry was present in almost all cases. We attribute our excellent elevation and perfect symmetrical results to the application of a single long curved haemostat instead of the usual two thin curved haemostats. Use of this single haemostat was considered superior because the curve of the haemostat could be easily adjusted to be uniformly parallel to the lid margin, thereby avoiding any lid notch or any asymmetry. Moreover, this was found to be technically simple in performing operation.
Lauring also reported 2 cases in which persistent mucoid discharge and granulation tissue was seen. This post operative complication was not seen in any of our cases. Mild entropion occurred in 5 eyes (10%). Entropion could be explained due to the posterior lamellar shortening. In majority of our cases eye lid elevation was achieved within 2 to 3 weeks, as in cases reported by Lauring.
Thus, it is concluded from this large series that this simplified technique is quick, safe, effective and can be performed as an OPD procedure. Ptosis correction is excellent without any major complications.
| References|| |
Fasanella R.M., Servat J : Levator resection for minimal ptosis: Another simplified operation. Arch. Ophthalmol 65:493496, 1961.
Beard C. : Ptosis, St. Louis, C.V. Mosby Co, P 136-138, 1981.
Beard C.: Blepharoptosis repair by modified Fasanella-Servaf operation. Am J. Ophthalmol 69:850-857, 1970
Fasanella R.M. : Surgery for minimal ptosis: The Fasanella - Servat operation, Trans Ophthalmol Soc U.K. 93:425-438, 1973.
Crawford J.S.: Repair of blepharoptosis with a modification of the Fasanella - Servat operation. Can. J. Ophthalmol 8:19-23, 1973.
Fox S.A.: A modified Fasanella - Servat procedure for ptosis, Arch. Ophthalmol 93:639-640, 1975.
Lauring L. : Blepharoptosis Correction with the sutureless Fasanella - Servat operation. Arch. Ophthalmol 95:671-674, 1977.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]
[Table - 1], [Table - 2], [Table - 3]