Good Levator Function Research Articles

Surgical Correction of Blepharoptosis Using the Levator Aponeurosis–Müller’s Muscle Complex Readaptation Technique: A 15-Year Experience

Palpebral ptosis is defined as abnormal drooping of the upper lid, caused by partial or total reduction in levator muscle function. It may be caused by various abnormalities, both congenital and acquired. The aim of this article is to report the long-term follow-up of results obtained with the levator aponeurosis-Müller's muscle complex readaptation technique. In a clinical study, 144 eyelids (102 patients) affected by congenital or acquired blepharoptosis were treated using the levator aponeurosis-Müller's muscle complex readaptation technique. Degree of ptosis and levator function were measured preoperatively and postoperatively. All patients were followed up for 1 year, 54 of them for 3 years, 22 for 5 years, and 12 for 10 years. Complete correction or mild residual ptosis was achieved in over 83 percent. All ptosis with preoperative levator function greater than 8 mm was completely corrected, whereas eyelids with poor or absent levator function showed a variable degree of postoperative correction and a statistically significant difference. Ptosis correction between eyelids with levator function greater than 8 mm or less than 8 mm was analyzed statistically using the McNemar test for paired data. This surgical technique is effective in both acquired and congenital ptosis. In particular, the authors obtained better results in those with fair to good (> 8 mm) levator function than in those with poor or absent (< or = 8 mm) levator function.

Strategies for Simultaneous Double Eyelid Blepharoplasty in Asian Patients With Congenital Blepharoptosis

Most patients with blepharoptosis prefer to undergo a double eyelid operation and a ptosis repair simultaneously to achieve the optimal cosmetic and functional result. However, it is difficult to achieve symmetry in patients with blepharoptosis. Surgery was performed on the levator aponeurosis or frontalis muscle to correct blepharoptosis while double eyelid surgery was simultaneously performed to correct blephroptosis in 264 patients over the past 15 years. This report describes 39 representative cases of unilateral congenital blepharoptosis and 30 representative cases of bilateral congenital blepharoptosis. In cases of unilateral ptosis with good or fair levator function, a levator resection or plication was performed, and the position of the lid margin was adjusted to 1 to 2 mm below the upper limbus. Cases of severe unilateral blepharoptosis were corrected by frontalis muscle flap, orbicularis oculi muscle flap, or frontalis myofacial flap, and the height of the double eyelid was created to be 1 to 2 mm less than the height on the normal side. The position of the lid margin was adjusted to the level of the superior limbus, and the height of the lid crease of the ptotic eye was determined to be according to that on the nonptotic side. For bilateral ptosis patients with equal levator function, the height of the double eyelid was designed symmetrically. Bilateral blepharoptosis patients with unequal levator muscle function should have the double eyelids on both sides created the same as in normal cases, and they must be grafted in proportion to the severity of the blepharoptosis. If the results are unpredictable, the two-stage operation should be performed. Only 30% of the eyelids in this study were perfectly symmetric after the blepharoptosis operation, with 70% asymmetric. These 70% showed good symmetry immediately after surgery, but asymmetry occurred 6 months after the operation. In blepharoptosis surgery, different techniques for double eyelids must be applied according to the method of ptosis correction used. Usually, the height of the double eyelid on the ptotic side should be a little less than the normal double eyelid height on the nonptotic side. However, it is difficult to achieve symmetric double eyelids in blepharoptosis patients.

Isolated Muller's muscle resection for the correction of blepharoptosis

To assess the outcome of isolated Muller's muscle resection with preservation of conjunctiva in patients with blepharoptosis and good to moderate levator function. This study was designed as a prospective, nonrandomised case series. Thirty-four eyes of 27 blepharoptosis patients were operated on, who were phenylephrine test-negative as well as positive. Open-sky Muller's muscle resection was performed with preservation of the conjunctiva. Main outcome measures were increase in margin reflex distance (MRD1), eyelid contour, and symptoms and signs of dry eye. The mean increase in MRD1 was 2.75 mm. All but one patient (96%) had upper lid margins resting at or up to 1 mm below the limbus and obtained symmetry to within 0.5 mm of the fellow eye. No patients had symptoms or signs of dry eye. Isolated Muller's muscle resection is effective for the correction of ptosis in patients with moderate to good levator function. This is irrespective of the lid's response to phenylephrine. Preservation of conjunctival tissue eliminates concerns about dry eye, and also preserves the full height of the fornix.

Cosmetic outcome of three sutures levator aponeurosis tuck procedure in congenital ptosis.

To determine the results of three sutures aponeurosis tuck procedure in patients with congenital ptosis. A quasi-experimental study. Department of Ophthalmology, Khyber Teaching Hospital, Peshawar from January 2004 to January 2005. Twenty-four eyes of 20 patients (13 males and 7 females) with congenital ptosis were included in the study. All these lids had either good or fair levator function. Amount of ptosis in all lids were measured before surgery and their mean calculated. Single surgeon performed the three sutures levator aponeurosis tuck procedure on all these lids. Degree of ptosis, after surgery was measured on multiple occasions and mean of measures of last follow-up was calculated. At this stage, the patients' satisfaction level was also documented. Mean amount of ptosis was 3.25 +/-0.99 mm before surgery and 0.33 +/- 0.56 mm after surgery (p < 0.0001). Satisfaction level of 18 (90%) patients was 70-90%, while in 2 (10%) patients it was 50-60%. Levator aponeurosis tuck procedure had good cosmetic outcome in patients with congenital ptosis having good and fair levator function in this series.

Mini-Invasive Ptosis Surgery

Background and objective: Levator aponeurosis advancement is an effective technique that is routinely used to correct aponeurogenic ptosis. The standard technique involve a skin incision of the upper eyelid crease for the entire length of the eyelid, with or without associated blepharoplasty. We believe that, in a selected group of patients, a less invasive approach with an upper lid skin incision of only 0.8 cm is equally effective for the final result and offers several advantages compared to the traditional technique. Materials and methods: We retrospectively reviewed the data of 48 patients affected by involutional ptosis with good levator function that underwent unilateral or bilateral levator advancement ptosis repair through a mini-invasive approach. Final outcome measures included postoperative eyelid height, contour, symmetry, periocular edema, surgical time and visibility of the incision site. Results: The mini-invasive approach for the correction of involutional ptosis resulted in our hands as effective and reliable as the traditional technique, required a shorter surgical time, offered an improved early post-operative course with minimal bruising and swelling and produced no visible scar. Conclusions: This mini-invasive ptosis correction technique replaced in our practice the traditional approach for the treatment of a selected subset of patients affected by aponeurogenic ptosis.

Avaliação dos resultados cirúrgicos com a técnica da ressecção do músculo de Müller-conjuntiva no tratamento da blefaroptose

To evaluate the results of Müller's muscle-conjunctival resection for correction of blepharoptosis and to discuss the advantages of this procedure. 38 patients (39 eyelids) were submitted to Müller's muscle-conjunctival resection. Blepharoptosis varied from 1.0 mm to 3.0 mm (mean: 2.0 mm). The amount of eyelid elevation produced by phenylephrine guided the amount of tissue to be resected. 33 eyelids (85%) treated with this procedure were cosmetically acceptable. Müller's muscle-conjunctival resection procedure is a relatively simple technique for blepharoptosis, with good levator function and positive 10% phenylephrine test. The advantages are: preservation of tarsus and predictable results.

Tratamiento quirúrgico de ptosis palpebral miogénica adquirida

To report the surgical outcome of aponeurosis surgery in patients with acquired myogenic eyelid ptosis and describe surgical guidelines for their correction. The clinical records of two patients with acquired myogenic eyelid ptosis after surgical correction were reviewed. In two patients with acquired myogenic eyelid ptosis and barely good levator function, levator resection surgery was performed. Corneal complications appeared in both cases. Patients with acquired myogenic eyelid ptosis are at risk of post-operative surgical complications from corneal exposure. Surgical correction should be conservative and performed only when the visual axis is compromised.

Progressive External Ophthalmoplegia With Hereditary Sensory Neuropathy: A Rare Association

We describe a patient with chronic progressive external ophthalmoplegia and hereditary sensory neuropathy, an association not previously reported. A 7-year-old girl presented with drooping of both eyelids and inability to look up since age 4 years. There was no history of trauma or swelling of eyelids. From age years, the child had had recurrent ulcers on her fingertips, toes, and the dorsum of her hands and feet without pain. No family member had a similar problem. The child was of below-average intelligence. We noted auto-amputation of the great and small toes, mutilated right nail beds on the other toes, multiple scar marks on the dorsum of both feet, mild pes-cavus on the right, and mutilated nail beds and multiple scar marks on the dorsal surfaces of both hands (Fig. 1). We also found distal weakness of both upper and lower extremities, absent knee and ankle jerks bilaterally, and a decrease in all modalities sensation, greatest distally.FIG. 1: The dorsum of hands and feet show auto-amputation of fingertips and toes, mutilation, and multiple scar marks.Cranial nerve examination was normal. There were no hypopigmented anesthetic skin patches or thickened nerves. Visual acuity was finger counting OU. Visual fields were normal bilaterally. She had mild ptosis with good levator function bilaterally. Ocular movements were markedly reduced in upgaze and downgaze but full in horizontal gaze with nystagmus in extreme lateral gaze (Fig. 2). An alternating 20-prism-diopter exotropia was present without diplopia. Corneal sensation was mildly decreased. Pupils were normal in size and shape and reacted briskly to light. Ultrasound of both orbits was normal. The neostigmine test was negative. Complete blood profile, erythrocyte sedimentation rate, serum protein electrophoresis, thyroid profile, and brain magnetic resonance imaging were normal. A nerve conduction study showed absent sensory conduction in median, ulnar, and sural nerves and decreased motor conduction in median, ulnar, and common peroneal nerves. These findings favored a diagnosis of hereditary motor sensory neuropathy type 1. No other siblings or parents had this condition. However, the parents were consanguineous.FIG. 2: Mild bilateral ptosis, reduced upgaze and downgaze, and nearly normal horizontal gaze.In a 1980 study of 228 patients of hereditary sensory neuropathy, Harding et al (1) did not find a single case of external ophthalmoplegia. Pramod Kumar Sahu, MD, FRCS (Edin) V. A. Rao, MD Renuka Srinivasan, MS S. Thanikachalam, MD Department of Ophthalmology, Jawaharlal Institute of Postgraduate Medical Education & Research Center; Pondicherry, India; E-mail: [email protected]

Open sky Müller's muscle-conjunctiva resection for ptosis surgery.

We describe a surgical technique for ptosis correction in moderate to good levator function involving resection of Müller's muscle of the upper eyelid. This is a substantial modification of the technique described by Putterman. We then present our experience of and the results from this method. A subtotal resection of Müller's muscle plus underlying conjunctiva is performed under direct visualisation. The muscle stump is reattached to the tarsus and the sutures passed through to the skin crease. In those cases where the phenylephrine test was positive to a level less than the desired lid height, a 1 mm of strip of tarsus is included in the tissue resection. The sutures are removed between 5 days and 3 weeks postoperatively allowing control over lid height and contour. A total of 61 eyes of 48 patients underwent this procedure. Of 61 eyelids, 56 undergoing this procedure were within 0.5 mm of the desired end point, giving a success rate of 92%. Of 61 eyelids, 60 were within 1 mm of the desired height. Preoperative phenylephrine 10% was highly predictive of postoperative lid height (58/61). An excellent lid contour was noted in all cases (61/61). We present a new approach to ptosis correction using Müller's muscle. It has a high success rate and good cosmetic outcome. It is technically straightforward and easy to learn.

Further Modifications of the Müllerʼs Muscle-Conjunctival Resection Procedure for Blepharoptosis

A modified Müller's muscle-conjunctival resection procedure was performed to correct minimal to mild blepharoptosis with good levator function. A semilinear formula was used to excise specific amounts of Müller's muscle for different amounts of blepharoptosis. This formula was modified by less than adequate responses with the phenylephrine test. The phenylephrine test was also used to unmask contralateral ptosis so that bilateral surgery or less resection on the primarily ptotic eye could be planned. This modified technique and formula provides an approach to better quantitate minimal to mild ptosis surgery and yield more predictable results.

Upper Eyelid Ptosis Correction by a Revised Tarsal Resection Technique

Many techniques have been developed for the correction of eyelid ptosis. A new tarsal plate resection technique is described for use in cases of minimal ptosis with fair to good levator function. The procedure involves a horizontal lenticular excision of the tarsal plate, placed so that equal amounts of tarsus remain above and below the excision. The height of the excision is equal to the amount of ptosis correction desired, as determined in the preoperative examination. This precision in surgical correction is the chief advantage of the procedure. The technique also spares Müller's muscle, thus retaining the lid-elevating action of that muscle. Good results have been achieved in 6 patients, some showing excellent results after nine years.

Pseudoptosis in a patient with maxillary sinus mucocele

The authors examined a patient who complained of ptosis on the right side. Examination of the affected eye revealed a narrow lid fissure, an upward displaced globe, and good levator function. Computed tomography indicated a right maxillary sinus mucocele with an intraorbitally displaced bone fragment of the orbital floor. The mucocele was excised and the orbital floor was reconstructed surgically. Immediately thereafter the right lid fissure opened to normal size. The authors believe that the small lid fissure simulating ptosis in this patient may have been caused by the mucocele, suggesting that maxillary sinus mucocele should be added to the list of factors predisposing to pseudoptosis.

The Levator Muscle in Cosmetic Blepharoplasty

The levator muscle in cosmetic blepharoplasty was the topic discussed by Dr Ferdinand Becker, Vero Beach, Fla, at the spring meeting of the American Academy of Facial Plastic and Reconstructive Surgery in Palm Beach, Fla. Ptosis is quite common and must be considered when a patient asks for correction of his eyelids. Blepharoplasty alone will not suffice. Dr Becker classifies ptosis as congenital and acquired. Patients with congenital ptosis give a history of a lifetime problem and should be referred to the oculoplastic surgeon. Acquired forms are due to detachment of the levator aponeurosis at the tarsal plate. Also, simple self-inflicted trauma imposed on involutional atrophy of the levator aponeurosis may be sufficient to cause ptosis. The classic appearance is ptosis with a high lid crease, which is evidence of good levator function. The limbus diameter is 11 mm; normally, 2 mm of the cornea is covered by the upper

Ptosis associated with fatty infiltration of Müller's muscle and levator muscle.

Prominent fatty infiltration of Müller's muscle and the anterior levator muscle was noted at the time of surgery in nine of 115 patients undergoing external levator resection for ptosis. This distribution of adipose tissue was confirmed by light microscopy. Fatty infiltration appeared to be a degenerative change found in adults with congenital and acquired ptosis. Preoperatively these patients exhibited moderate to severe ptosis, fair to good levator function, and no elevation of the lid crease. The desired postoperative results were achieved with standard external levator resection and advancement techniques. The fatty appearance may lead to difficulty in identifying customary anatomical landmarks during surgery. With the exception of Horner's syndrome, abnormalities of Müller's muscle have not previously been described in association with ptosis, to these authors' knowledge.

Involutional ptosis: recognition and management.

Involutional ptosis is a ptosis of varying degree. There is good levator function with a high lid fold and increased lid excursion on downgaze. There may be increased translucency of the upper lid. We reviewed all adult ptosis cases over the past three years at Sydney Eye Hospital and found 20 cases to have aponeurotic defects such as a dehiscence or disinsertion. Ninety percent of our cases had a positive 10% phenylephrine test. We recommend that all operations be done under local anaesthesia without adrenaline, overcorrecting by 1-2 mm at the time of surgery.

Treatment of Small to Moderate Amounts of Ptosis with Good Levator Function

Treatment of Small to Moderate Amounts of Ptosis with Good Levator Function

Treatment of Small Degree of Ptosis with Good Levator Function

Treatment of Small Degree of Ptosis with Good Levator Function

Modifications of the Müller's Muscle-Conjunctival Resection Operation for Blepharoptosis

We used a modified Müller's muscle-conjunctival resection operation to correct cases of minimal blepharoptosis with good levator function. After we everted the eyelid, we placed a marking suture through the conjunctiva and Müller's muscle 4 mm above the superior tarsal border. The suture was used to tent up Müller's muscle and the conjunctiva from the underlying levator aponeurosis, facilitating placement of a resection clamp. These improvements ensure excision of the proper amount of tissue and reduce intraoperative trauma. Eighteen (95%) of 19 eyelids treated with this modification were cosmetically acceptable.

Experience with the Fasanella-Servat Operation for Ptosis of the Upper Eyelid

A quick, simple, and reliable operation for the correction of mild to moderate ptosis in the presence of fair to good levator function was described by Fasanella and Servat nearly two decades ago. This operation consists of resection of the conjunctiva, tarsus, and müller's muscle using a conjunctival approach. We have performed this operation in 39 patients with good to excellent results in 38. Our criteria and experience are described.