Management of myopathic ptosis

Abstract

In their article, Wong et al1Wong V.A Beckingsale P.S Oley C.A Sullivan T.J Management of myogenic ptosis.Ophthalmology. 2002; 109: 1023-1031Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar nicely described the features that characterize patients with progressive myopathic ptoses, including mitochondrial myopathies, oculopharyngeal muscular dystrophy, oculopharyngodistal myopathy, and myotonic dystrophy. The eye manifestations that these patients experience, including progressive visually significant ptosis, poor levator excursion, poor ocular motility, poor or absent Bell's phenomenon, lagophthalmos, and, in some cases, decreased tear function, may lead to corneal exposure keratopathy and ocular discomfort. Wong et al liberally recommend silicone sling operations for patients with <8 mm of levator excursion or levator resection and advancement for patients with >8 mm of levator function. In their case series, they do not report preoperative levator excursion, lagophthalmos, Bell's phenomenon, or dry eye measurements. They do report an overall complication rate of 32% (9/28 patients), with “corneal desiccation problems” in 21% (6/28 patients); 3 of their patients required consecutive surgery to reverse the corneal exposure problems. Despite the high rate of exposure keratopathy, they do not advocate using our modified blepharoplasty technique because of the “risk” of exposure and ptosis recurrence.2Burnstine M.A Putterman A.M Upper blepharoplasty. A novel approach to improving progressive myopathic blepharoptosis.Ophthalmology. 1999; 106: 2098-2110Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar We, however, advocate upper blepharoplasty in these challenging ptosis cases to create a physiologic sling between the eyebrow and eyelid. Upon eyebrow elevation, the upper eyelid elevates. The sling effect is created without exogenous material, thus decreasing the chance of infection, implant exposure, or dehiscence and regression of eyelid elevation. In our 6 patients, we had no postoperative lagophthalmos, corneal exposure keratopathy, or ocular desiccation complaints; we had one revision surgery to remove additional skin because of unappreciated eyebrow ptosis in the preoperative period. When performed correctly, eyelid elevation does not result in corneal exposure keratopathy. In patients with myopathic ptosis, liberal levator resections and advancements and silicone sling placement should be avoided. Management of myopathic ptosis: Author replyOphthalmologyVol. 111Issue 2Preview Full-Text PDF