Assessment of ptosis and documentation

Ptosis is documented by the margin to reflex distance 1 (MRD₁)⁴, which is the distance from the central pupillary light reflex to the upper eyelid margin, measured in millimeters. It is important to document the amount of ptosis to the nearest 0.5 mm, if possible. The margin to reflex distance 2 (MRD₂) is the distance from the central pupillary light reflex to the lower eyelid margin. The MRD₁ plus the MRD₂ should equal the palpebral fissure.

The levator excursion test is the best clinical means for assessing levator function. The levator excursion is documented in millimeters, measuring the distance from extreme upgaze to downgaze with the brow immobilized by the examiner’s thumb to eliminate any contribution of the brow to lid elevation. A millimeter ruler is used vertically in the pupillary axis to assess the full excursion. Levator excursion of 10 mm or greater is considered good function; 5–9 mm of excursion is fair function; and 4 mm or less is poor function.

Patients with minimal ptosis (2 mm or less) should have a phenylephrine test performed in the involved eye or eyes after appropriate ptosis measurements have been documented. Either 2.5% or 10% phenylephrine is instilled in the affected eye or eyes. We prefer to use 2.5% phenylephrine. Usually two drops are instilled and the patient is re-examined 5 minutes later. The MRD₁ is rechecked in the affected and unaffected eyes (Fig. 48.2). A rise in the MRD₁ of 1.5 mm or greater is considered a positive phenylephrine test. This indicates that Müller’s muscle is viable, and the Müller’s muscle conjunctival resection procedure can be performed, also giving the patient a reasonable prediction of the desired result.

Fig. 48.2 The phenylephrine test. (A) The margin-to-reflex distance (MRD₁) is measured on both upper eyelids and repeated 5 minutes after instillation of 2.5–10% phenylephrine eye drops in the ptotic eye. (B) The right upper eyelid responds to the stimulating effects of the phenylephrine and shows a reduction of the ptosis (an increase in the MRD₁).

The contralateral eye must also be rechecked in patients with unilateral ptosis. When the ptotic eye is occluded, if the MRD₁ decreases appreciably in the opposite eye, this usually indicates that bilateral ptosis is present; this finding is consistent with Hering’s law⁵. The patient may require bilateral surgery. A negative phenylephrine test precludes the use of the Müller’s muscle conjunctival resection procedure, because the outcome of the procedure is unpredictable in this setting. Callahan and Beard³ have stated that minimal or mild ptosis is 2 mm or less, moderate ptosis is 3–4 mm, and severe ptosis is 4 mm or greater. Usually patients with minimal ptosis will have good levator excursion. The moderate ptosis patients usually have good to fair excursion, and typically patients with severe ptosis have poor levator excursion.

Surgical options based on levator function

For patients with minimal ptosis (2 mm or less) there are three surgical options: (i) Müller’s muscle conjunctival resection, (ii) the Fasanella–Servat procedure, or (iii) levator aponeurotic surgery. If the phenylephrine test is positive, the Müller’s muscle conjunctival resection procedure is the most precise and predictable surgical option⁴. For many ptosis surgeons, this is the preferred approach for minimal ptosis because of its ease, predictability, and the ability to grade or titrate the correction according to the pre-established nomograms. The surgeon can also calculate, with time and personal experience, his or her own nomogram⁶. If, however, the phenylephrine test is negative, one must consider other procedures because of the unpredictability of Müller’s muscle conjunctival resection in this subset of patients. The Fasanella–Servat procedure is the next option for minimal ptosis and a negative phenylephrine test. The Fasanella–Servat procedure is nearly as predictable as Müller’s muscle conjunctival resection and equally easy to perform⁷. Because it is in a sense a tarsectomy with little Müller’s muscle resected, it is viable in the absence of a positive phenylephrine test.

Levator aponeurosis repair is the third option for minimal ptosis. Many surgeons prefer this technique because it allows them to set the eyelid height while the patient is on the operating table. It is particularly useful for patients who have contour abnormalities and who have ptosis that requires concomitant blepharoplasty⁵. There are, however, many variables that may affect the results, including the need for patient cooperation, the effects of sedation or local anesthetic infiltration, and the need to over-correct the affected side or sides. It is also difficult to grade the degree of correction under general anesthesia. Indeed, many reports have suggested that predictability and success with this procedure may vary by as much as 2 mm between the two affected eyelids^8,9. In the setting of minimal ptosis, however, success ought to be judged to within 0.5 mm. Nonetheless, levator aponeurotic repair is useful for many minimal ptosis patients.

Levator aponeurosis repair is the treatment of choice for nearly all patients with moderate ptosis. These patients usually have good to fair levator excursion, and they usually have negative phenylephrine tests. Patients with severe ptosis typically have poor levator excursion and require some type of frontalis suspension. Patients with unilateral congenital ptosis and levator excursion of only 4–5 mm are often helped with Whitnall slings or maximal levator aponeurotic advancement. This treatment can be augmented by simultaneous tarsectomy as well.

Bilateral severe ptosis patients, or patients with very poor levator excursion, need some type of frontalis suspension. Congenital severe ptosis with little levator excursion is best served with autogenous fascia lata sling grafts. Non-autogenous materials are available and can be used, if necessary; however, the long-term results are poorer than with autogenous materials¹⁰. Acquired severe ptosis, as seen with third nerve palsy, progressive external ophthalmoplegia, or oculopharyngeal dystrophy, is best treated by frontalis suspension sling with a silicone rods¹¹ (Silastic) or more recently expanded polytetrafluoroethylene (ePTFE) because of its adjustability and the possibility for subsequent removal if the cornea becomes compromised.

Müller’s muscle conjunctival resection

Müller’s muscle conjunctival resection is reserved for patients with minimal ptosis (2 mm or less) with normal levator excursion and a positive phenylephrine test. Putterman and Urist¹² originally described this technique in 1975. Various modifications have since been described^4,13.

Müller’s muscle is a smooth muscle that originates from the undersurface of the levator and inserts with a 0.5–1 mm tendon into the superior tarsal plate¹⁴. When denervated in Horner syndrome, this muscle relaxes causing 2–3 mm of clinical blepharoptosis. The levator aponeurosis has been shown to insert on the anterior surface of the tarsus within 7–8 mm of the upper tarsal border. Additional interdigitations with the intermuscular septum of the orbicularis oculi form the eyelid crease¹⁵. Whitnall, however, recognized Müller’s muscle as another important primary attachment or insertion of the levator. When Müller’s muscle is advanced it strengthens the posterior lamella and appears to plicate the levator aponeurosis, with healing and subsequent scarring in the posterior lamella. This plication is successful in maintaining constant elevation of the upper eyelid in the open eyelid positioning primary gaze⁴.

Surgical technique

A frontal nerve block is unnecessary for the procedure; 1% or 2% xylocaine is used as a regional block for the upper eyelid. Epinephrine is omitted to avoid stimulation of Müller’s muscle. Approximately 5 cc of the solution, mixed with hyaluronidase (10 cc of anesthetic is mixed with 150 units of hyaluronidase), is injected just below the superior orbital rim. Tetracaine topical anesthetic eye drops are then placed on the conjunctival surface. A 4-0 silk suture is placed through the tarsus at the eyelid margin in the pupillary axis. The eyelid is reflected over a Desmarres retractor. Marks are made at one-half the distance of the total resection amount medially, centrally, and laterally, measured with a caliper, and beginning 0.5 mm above the tarsal plate. Another mark is made centrally to measure the total extent of resection desired⁷ (Fig. 48.3).

Fig. 48.3 Müller’s muscle conjunctival resection. A 4-0 silk traction suture is placed through the tarsus and the eyelid is reflected over a Desmarres eyelid retractor. Marks are made medially, centrally, and laterally at one-half the distance of the total vertical amount of resection desired. A separate mark is made centrally to indicate the height of the total resection desired.

Three 4-0 silk traction sutures are placed through the conjunctiva and Müller’s muscle centrally, medially, and laterally at the halfway marks. Each bite is approximately 3 mm long and deep to the underlying Müller’s muscle but should not penetrate to the levator aponeurosis or orbicularis muscle. The sutures are separated into two bundles and tied on themselves, to be used as traction sutures to elevate the required amount of conjunctiva and Müller’s muscle to be resected (Fig. 48.4)⁷.

Fig. 48.4 Müller’s muscle conjunctival resection. Three 4-0 silk traction sutures are placed through Müller’s muscle and conjunctiva.

The Desmarres retractor is removed and the lid margin suture is clamped superiorly to the head drape. The bundles of sutures are elevated, with one bundle held by the surgeon and the other by an assistant. The Müller’s muscle conjunctival resection clamp is placed over the elevated tissues. The clamp is placed so that the most superior central mark is adjacent to the resection clamp. The authors prefer the use of a Dresner-Uzcategui (Storz E2512) ptosis clamp, although a Putterman Muller’s Muscle Conjunctival Resection Ptosis Clamp Storz Catalog # E2508 is also an acceptable alternative (Bausch & Lomb Inc. 1 Bausch and Lomb Place. Rochester, NY 14604-2799 Ph: (585) 338-6000).

A 6-0 plain horizontal mattress suture is placed under the clamp in a running fashion, approximately 0.5–1 mm below the clamp (Fig. 48.5). The conjunctiva is closed with a running baseball stitch in the reverse direction of the original pass. The suture is tied on itself (Fig. 48.6)⁷. Exteriorizing the suture is not required. The clamped tissues are excised with a no. 15 blade metal on metal (Fig. 48.7). The eyelid is returned to its anatomic position, and the eyelid margin suture is removed.

Fig. 48.5 Müller’s muscle conjunctival resection. The sutures are elevated in two bundles and the clamp is placed over the tissues. A 6-0 plain catgut suture is placed underneath the clamp.

Fig. 48.6 Müller’s muscle conjunctival resection. The conjunctiva is closed with the 6-0 fast absorbing plain gut suture.

Fig. 48.7 Müller’s muscle conjunctival resection. The clamped tissues are incised with a no. 15 Bard–Parker blade, along the lower edge of the clamp.

Alternatively a 6-0 Prolene suture can be used; for this modification, the suture should enter from the anterior lamella full thickness and placed under the clamp in the same way described above. This suture needs to be exteriorized and, after excising Müller’s muscles and conjunctiva, conjunctival closure is not necessary. Both ends of the exteriorized Prolene suture are tied to each other once the eyelid is back to its anatomic position. The suture is removed after 5–7 days. Antibiotic ointment is placed in the eye and no patch is necessary. Excellent results can be seen, with minimal ptosis ranging between 1 and 2 mm (Fig. 48.8). The advantages of this technique are that it is quick, predictable, and quantifiable. Late failures are rare. Complications include a rare superior corneal abrasion, under-correction, or over-correction. Usually an abrasion heals spontaneously if it is small. A bandage contact lens can also be placed if desired. Over-correction is rare with this technique. If it occurs, the plain suture can be cut under topical anesthetic in the office, and the wound can be separated gently with a cotton swab. Under-correction requires another procedure at a later date (Table 48.1).

Fig. 48.8 Preoperative (A) and postoperative (B) photographs of a man with 2 mm of ptosis left upper lid, showing the results of Müllerectomy.

Table 48.1 Resection nomogram for Müller’s muscle conjunctival resection

Amount of ptosis in mm	Amount of MMCR resection
0.5–1 mm	4 mm
2 mm	8 mm
3 mm	10 mm
>3 mm	Not recommended

Courtesy of S. Dresner.

Levator aponeurosis repair

Levator aponeurosis repair is useful for minimal to moderate ptosis and can be employed when Müller’s muscle conjunctival resection or Fasanella–Servat are not indicated, as in the patient with a large conjunctival filtering bleb or when concomitant blepharoplasty it desired. For moderate ptosis (3–4 mm), it is the procedure of choice. A maximal levator aponeurotic advancement or Whitnall sling can be employed for patients with severe unilateral ptosis; excising additional amounts of tarsus to elevate the eyelid margin can further augment it.

The levator palpebrae superioris extends from the annulus of Zinn traveling anteriorly through the superior orbit to Whitnall’s ligament, which serves as a suspensory ligament for the upper eyelid (Fig. 48.9). At this point the muscle appears aponeurotic and has a whitish color. The levator aponeurosis courses downward to insert on the inferior two-thirds of the anterior surface of the tarsal plate, the fibrous septi of the orbicularis, and the subcutaneous tissues¹⁶. Anterior to the levator aponeurosis is the preaponeurotic fat pad and the orbital septum.

Fig. 48.9 Levator aponeurosis repair. Schematic line drawing of upper lid. The levator muscle extends from the annulus of Zinn anteriorly to Whitnall’s ligament, where it transitions into the levator aponeurosis. It courses downward to insert into the anterior two-thirds of the tarsal plate.

Surgical technique

The procedure is best performed under local anesthesia with minimal intravenous sedation; small amounts of local anesthetic are used to avoid paralyzing the levator muscle. Epinephrine is recommended for adequate hemostasis. Approximately 1–2 cc of 1% xylocaine with epinephrine is usually sufficient. The eyelid crease should be marked prior to local infiltration. If unilateral ptosis is to be performed, the incision is marked approximately 1 mm below the crease on the opposite eyelid. Postoperatively the crease will rise slightly. If bilateral surgery is planned, the incision can be symmetrically placed at the desired location, but placing the incision too high beyond the superior tarsal border of the upper tarsus should be avoided.

After the local anesthetic is injected into the eyelid, topical tetracaine eye drops are placed on the conjunctival surface. The patient is prepped, and protective corneal shields can be placed over the globes. The incision can be made with a no. 15 Bard–Parker blade, a Colorado needle tip (Colorado Biomedical, 6851 Highway 73 Evergreen, CO 80439) in cut mode, or a CO₂ laser set to incisional mode. A skin muscle flap is developed to expose the orbital septum. The septum is incised over the upper one-third to avoid incising or damaging the underlying levator (Fig. 48.10)¹⁷. The pre-aponeurotic fat pad is reflected upward to reveal the whitish aponeurosis beneath. A high temperature hand-held cautery is used to disinsert the aponeurosis from the tarsal plate, which separates the aponeurosis from the underlying Müller’s muscle (Fig. 48.11). Dissection is carried upward, as high as Whitnall’s ligament if necessary. A double 5-0 Vicryl suture is placed partial thickness through the central portion of the upper tarsus in two 3 mm bites. This suture is then taken up through the aponeurosis at the desired height (Fig. 48.12). This is temporarily tied and the level is examined. Usually sitting the patient up on the table gives a more accurate assessment. A 1–1.5 mm over-correction is desirable because the protractors (orbicularis) are paralyzed by local anesthetic and there can be some stimulation of Müller’s muscle by the epinephrine. Additional sutures can be placed medially and laterally for contour adjustment; often, however, they are unnecessary. The excess levator aponeurosis is trimmed. A strip of skin-orbicularis flap superiorly can be excised if necessary, or bilateral blepharoplasties can be performed. The wound is then closed with a 6-0 suture of choice with supratarsal fixation on every other bite of the suture. Excellent results can be obtained with this approach (Fig. 48.13).

Fig. 48.10 Levator aponeurosis repair. The orbital septum is transected in the upper one-third.

Fig. 48.11 Levator aponeurosis repair. The levator is dissected off of the tarsus with a hand-held cautery.

Fig. 48.12 Levator aponeurosis repair. Double-armed 6-0 Vicryl sutures are placed through the central superior tarsus in two broad bites and then up through the aponeurosis and tied.

Fig. 48.13 Preoperative (A) and postoperative (B) photographs of a man with bilateral ptosis, after levator aponeurosis resection.

Whitnall sling procedure

The Whitnall sling procedure is a maximal levator aponeurosis advancement. In actuality, the levator muscle’s Whitnall’s ligament is sewn to the superior tarsal plate, with no cutting of the medial and lateral horns of the levator and aponeurosis. This is usually employed in unilateral congenital ptosis with levator function in the 5 mm range.

Frontalis suspension using fascia lata

Patients with severe ptosis and poor levator function are candidates for frontalis suspension with autogenous fascia lata. Patients with synkinetic ptosis (Marcus–Gunn jaw-winking ptosis) may also be candidates for this procedure with or without levator extirpation. Generally, autogenous fascia lata gives more predictable and long-lasting results¹⁰. Eye bank preserved tissues can be utilized when the patient is younger than 3 years of age or at the family’s request.

Autogenous fascia lata is easily harvested ‘freehand’, obviating the need for any kind of fascial strippers. An incision of approximately 3–4 cm is marked in the mid-thigh longitudinally, halfway between the head of the fibula and the anterior superior iliac spine (Fig. 48.14). Although this procedure is usually performed under general anesthesia, 0.5% marcaine with 1 : 100 000 epinephrine is injected subcutaneously for hemostasis and postoperative analgesia. The foot is pronated slightly by a non-scrubbed assistant, or it can be taped to immobilize the leg and place the fascia lata on stretch. The incision is begun with a no. 15 Bard–Parker blade, and dissection is carried down through the subcutaneous fat to the fascia. For bilateral surgery, the harvested strip of fascia needs to be at least 6 mm in width and 8 to 10 cm in length. Two incisions are made 8–10 cm apart into the fascia with a no. 15 Bard–Parker blade. The fascia is exposed superiorly and inferiorly by dissecting bluntly with small ‘peanuts’ (small gauze-wrapped cotton balls). A surgical assistant moves along the incisions with army–navy retractors to expose the field. Using long Metzenbaum scissors, the fascial strips are incised lengthwise. Each strip is transected at both ends with curved scissors or Jorgenson’s scissors, and pulled out of the wound. The fascia lata is not repaired primarily. The subcutaneous tissues are closed with 4-0 or 5-0 Vicryl sutures, and the skin can be closed with a 5-0 plain gut suture.

Fig. 48.14 Frontalis suspension. A 3–4 cm incision is made at the lateral surface of the mid-thigh to obtain autogenous fascia lata.

Frontalis suspension using a silicone (silastic) rod

Silicone (Silastic) rod suspension is useful in myogenic ptosis conditions such as progressive external ophthalmoplegia, oculopharyngeal dystrophy, and myasthenia gravis, or in third nerve palsy patients. Rarely, an adult with severe bilateral congenital ptosis with no previous surgical correction or with under-correction from previous surgeries may present with absent or poor Bell’s protective eye phenomenon. These patients are usually better served with silicone rod frontalis suspension.

Silicone rod frontalis suspension is recommended in patients with progressive neuromuscular disorders and third nerve palsy because of the possibility of recovery from illness, possible favorable response to therapeutics, and allowance for postoperative adjustment. The 1 mm solid silicone (Silastic) rods are available commercially (Fig. 48.15). Some of the available silicone rod packages like the Seiff frontalis suspension set from BD Visitec™ Catalog# 585192 come with passing needles and a silicone sleeve, which eliminate the need for the Wright fascia lata needle (BD 1 Becton Drive, Franklin Lakes, NJ USA 07417 Ph: 201.847.6800). Some surgeons that find the metal trochard on the Seiff set to be not sturdy enough to withstand torque without bending, and they still prefer to use the Wright fascia needle. Using this instrument has two minor disadvantages that can be easily overcome: the Wright needle to pass the silicone needs to be done in a retrograde fashion and silicone has to be threaded into the needle. The silicone thread used by the authors (NU) when using the fascia needle is the Dyna Rod Prosthesis (Roger Klein Instruments, PO Box 501. Palmer, PR 00721 Ph: 787 8873405 Fax:787 888 8071). Other materials like ePTFE (Gore-Tex®) are available for this purpose, but the authors do not use this material routinely.

Fig. 48.15 Frontalis suspension. Commercially available Silastic rod set from Visitec (no. 5192; 7575 Commerce Court, Sarasota, FL 34243-3212). The set comes with 0.9 mm stainless-steel threading needles, a 40 cm length of Silastic rod, diameter 0.8 mm, and a 10 mm segment of Silastic sleeve that has an external diameter of 2 mm and an internal diameter of 1 mm.

Surgical technique

The surgery can be performed under general anesthesia or local anesthesia; however, local anesthesia is preferred because it allows the surgeon to fine-tune the eyelid level and contour intraoperatively. A simple pentagonal design similar to that used for the fascial frontalis suspension works well for this procedure. A lid crease incision, however, is more appropriate in this situation because it permits attachment of the silicone rod directly to the tarsal plate.

One percent xylocaine with epinephrine and hyaluronidase is injected under the lid crease incision and just above the eyebrow centrally, medially, and laterally. The lid crease incision is made and the tarsal plate is exposed by dissection through the orbicularis. The silicone rod is sewn onto the tarsal plate with three to five interrupted 6-0 braided nylon or polypropylene sutures (Fig. 48.16). The rod is then pulled up to the eyebrow to mark the medial and lateral brow incisions. This will help to optimize the contour of the upper eyelid margin. Incisions are made down to the periosteum. With the globe protected, in a similar fashion as described above, the rods are passed through the preaponeurotic space to the medial and lateral brow incisions with the passing needles (Fig. 48.17) or the Wright fascia needle. The medial and lateral ends of the silicone rod are then pulled up and crossed centrally to mark the central incision above the pupillary optic axis, which is usually above the pupil or just slightly medial to it. The two ends of the rod are passed through a small silicone sleeve to secure them at optimum length and tension. This maneuver can be performed using either a Watzke or a Lambert silicone sleeve spreader. The lid level is set between 1 and 3 mm above the pupil, depending on the condition being treated. (When dealing with adult myogenic or neurogenic ptosis, the surgeon should not elevate the margin of the superior eyelid to the limbus, as for correction of congenital ptosis.) The rods are trimmed and left with 5–8 mm at either end for possible future adjustment. The ends of these rods are then tucked into the wound. A 6-0 braided nylon or polypropylene suture is sewn around the sleeve, cutting into the silicone sleeve, which is then sewn superiorly to the deeper frontalis muscle (Fig. 48.18). The brow incisions are closed and the lid crease incision is closed, usually with supratarsal fixation every other bite to create a defined lid crease. One can adjust the lid level and contour postoperatively in the office by exposing the silicone sleeve under the central suprabrow incision. This is best done within the first few weeks after surgery, because once a pseudocapsule forms around the rods adjustment may prove to be more difficult. If indicated, the rod can be entirely removed at any time postoperatively. The silicone rod offers the extra advantage and flexibility of adjustability, and results comparable to those obtained with fascia lata techniques can be achieved (Fig. 48.19).

Fig. 48.16 Frontalis suspension. The Silastic rod is sewn to the tarsal plate.

Fig. 48.17 Frontalis suspension. The rods are passed through the preaponeurotic space to the medial and lateral suprabrow incisions.

Fig. 48.18 Frontalis suspension. The medial and lateral ends are crossed centrally to mark the exact central incision. The ends are passed through the central brow incision and then through the Silastic sleeve. The appropriate tension adjustment is made so that the lid is at the desired level and the contour is judged optimal. A 6-0 permanent suture is sewn around the sleeve and then stitched into the frontalis muscle under the superior edge of the incision.

Fig. 48.19 Preoperative (A) and postoperative (B) photographs of a woman with chronic progressive external ophthalmoplegia after frontalis suspension using Silastic rods.