Severe Unilateral Ptosis Research Articles

Surgical treatment of unilateral severe simple congenital ptosis.

Unilateral congenital ptosis with poor levator function of ≤4 mm continues to be a difficult challenge for the oculoplastic surgeon. Surgical correction can be accomplished with unilateral frontalis suspension, maximal levator resection, or bilateral frontalis suspension with or without levator muscle excision of the normal eyelid. Bilateral frontalis suspension was proposed by Beard and Callahan to overcome the challenge of postoperative asymmetry, allowing symmetrical lagophthalmos on downgaze, postoperatively. However, most surgeons and patients prefer unilateral correction on the abnormal eyelid either with a frontalis suspension or maximal levator resection. Frontalis suspension may be performed through the various surgical techniques using different autogenous or exogenous materials. Autogenous fascia lata is considered the material of choice with low recurrence rates but carries the drawbacks of the difficulty of harvesting and postoperative morbidity from the second surgical site. Recent reports have suggested that maximal levator resection provides improved cosmesis, a more natural contour, and avoids brow scars. Although both treatments have shown to have similar success rates, there is much debate about what the most favorable method for treating severe unilateral ptosis. We review the literature on the various surgical treatments for unilateral severe congenital ptosis, including the rationale, advantages and disadvantages of each technique.

A retrospective study: form‐deprivation myopia in unilateral congenital ptosis

Background: The aim of this retrospective study was to investigate the relationship between unilateral congenital ptosis in patients older than eight years and their refractive state and spherical equivalent refraction (SER).Methods: The study involved a review of the clinical records of 85 patients admitted to the First Affiliated Hospital, Sun Yat‐sen University between 1998 and 2010 with unilateral congenital ptosis. The average age was 16.83-years (nine to 27-years). The patients were classified into mild (27 cases), moderate (37 cases) or severe (21 cases) ptosis according to the degree of the droopy eyelid covering the cornea. The fellow eyes served as controls.Results: In 85 eyes with unilateral ptosis, the frequency of myopia (SER of ‐0.50-D or more myopia) was significantly higher than in the fellow eye (47 versus 32, p = 0.031). The frequency of myopia in eyes with severe unilateral ptosis was significantly higher than in the fellow eyes (16 versus 7, p = 0.012), whereas there were no significant differences in patients with mild (15/27 versus 13/27, p = 0.79) or moderate (16/37 versus 12/37, p = 0.47) unilateral ptosis. Similarly, the SER was significantly more myopic in eyes with severe ptosis compared with the fellow eye (‐1.37-D versus ‐0.85-D, p = 0.01), whereas no significant differences were found in patients with mild or moderate unilateral ptosis.Conclusions: The results showed a higher frequency of myopia and more myopic SER in eyes with severe unilateral ptosis compared with the fellow eye. The myopia found in eyes with unilateral ptosis might be caused by a mechanism similar to that resulting in myopia among animals subjected to form deprivation. It is important to pay attention to possible refractive error in patients with unilateral ptosis. Surgical correction of unilateral ptosis at an early age is recommended.

Tarsal resection operation in correction of severe unilateral blepharoptosis with poor levator function

There are many options for surgical repair of congenital unilateral ptosis with poor levator function. We performed resection of tarsus, Muller muscle, and conjunctiva in conjunction with an intraoperative adjustable levator resection. Resection of tarsus, Muller muscle, and conjunctiva in conjunction with levator resection was performed in a prospective series of 17 consecutive patients with unilateral ptosis with poor levator function over a 2-year period. Pre- and postoperative upper eyelid margin to reflex distance, degree of levator function, amount of operative tarsus and Muller muscle resection, postoperative eyelid symmetry, and postoperative complications were evaluated. Mean preoperative upper eyelid margin to reflex distance was 0.11 mm. Mean postoperative upper eyelid margin to reflex distance was 3.20 mm. Improved postoperative eyelid symmetry within 1.0 and 1.5 mm was demonstrated in most of our cases (58% and 76%, respectively). The major complication has been exposure keratitis. Resection of tarsus, Muller muscle, and conjunctiva combined with adjustable levator resection can correct severe unilateral ptosis with poor levator function.

Einseitige Brauensuspension bei schwerer einseitiger kongenitaler Ptose

The result of unilateral brow suspension in severe unilateral ptosis is said to be cosmetically and functionally not satisfactory. For the reason of symmetry, the myectomy of the levator muscle on the healthy side and the bilateral brow suspension have been recommended (Beard's law). However, we have successfully operated the affected side only in several patients without this far-reaching supplement.

Whitnall's Sling for Poor Function Ptosis

Severe unilateral ptosis with poor levator function has previously been treated with maximal levator muscle resection or bilateral or unilateral frontalis suspension. One of us (R.L.A.) has developed a technique called "Whitnall's sling," where only the levator aponeurosis is resected, preserving Whitnall's ligament and its attachments. Whitnall's ligament and the underlying resected levator muscle are sutured to the superior portion of the tarsal plate. This surgery preserves levator muscle, Müller's muscle, and Whitnall's ligament without altering the structures that produce the three-layer tear film. In 69 eyelids operated on between July 1976 and July 1986, in which a minimum of 1 year of follow-up by one of use was obtained, results have been satisfactory and directly related to levator function. We believe this technique to be anatomically and physiologically superior to "maximal levator resection" with similar long-term results. More recent results have shown that the addition of a 5-mm superior tarsectomy provides an additional elevation of 1 to 1.5 mm. Whitnall's sling is best suited for cases where the opposite fissure height is 9 mm or less and levator function of the ptotic eyelid is 3 to 5 mm.

Levator transposition and frontalis sling procedure in severe unilateral ptosis and the paradoxically innervated levator.

Symmetry in severe unilateral ptosis, the jaw-winking syndrome, and ptosis with aberrant third-nerve regeneration is best achieved with bilateral frontalis suspension. However, the levator function needs to be removed in the normal side with unilateral ptosis and bilaterally with the paradoxically innervated levator. Levator transposition to the arcus marginalis is a reversible methods of establishing a complete ptosis. the reversibility of the procedure is demonstrated in the rhesus monkey. The procedure, when combined with frontalis suspension in humans, demonstrates the needed elimination of levator function.