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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 110  |  Issue : 2  |  Page : 41-45

Evaluation of transconjunctival levator tucking for congenital ptosis


Department of Ophthalmology, Minia University Hospital, Faculty of Medicine, Minia University, Minia, Egypt

Date of Submission05-Feb-2017
Date of Acceptance21-Mar-2017
Date of Web Publication20-Jul-2017

Correspondence Address:
Mohamed F.S. Othman Abdelkader
Department of Ophthalmology, Minia University Hospital, Faculty of Medicine, Minia University, Minia, 61519
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejos.ejos_22_17

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  Abstract 

Purpose
The purpose of this paper is to evaluate the efficacy, cosmetic results, and safety of transconjunctival tucking of the levator aponeurosis for correction of simple congenital ptosis.
Patients and methods
This was a prospective interventional noncomparative case-series study. This study was carried out at the Ophthalmology Department of Minia University Hospital. Thirty eyelids of 24 patients with simple congenital ptosis with fair to good levator muscle function (≥5 mm lid elevation) were subjected to transconjunctival tucking of levator aponeurosis. All patients were subjected to an assessment of history and a full ophthalmological examination. The degree of ptosis was evaluated using marginal reflex distance 1. Levator muscle function was evaluated while fixing the eyebrow. Preoperative and postoperative digital photographs were used for documentation.
Results
Anatomical success was achieved in 26 (86.7%) eyelids. Undercorrection was present in four (13.3%) eyelids. No case of overcorrection was encountered. Undercorrection was associated with more severe ptosis and less levator muscle function. Good cosmetic outcomes were obtained in the majority of cases. Apart from undercorrection, no significant postoperative complications occurred during the study.
Conclusion
Levator aponeurosis tucking using the posterior transconjunctival approach is safe and effective for correcting simple congenital blepharoptosis, with good cosmetic outcomes. This technique is especially useful for mild and moderate cases of congenital ptosis associated with fair to good levator muscle function.

Keywords: congenital ptosis, levator aponeurosis tucking


How to cite this article:
Othman Abdelkader MF, Abdelrahman Abdallah RM. Evaluation of transconjunctival levator tucking for congenital ptosis. J Egypt Ophthalmol Soc 2017;110:41-5

How to cite this URL:
Othman Abdelkader MF, Abdelrahman Abdallah RM. Evaluation of transconjunctival levator tucking for congenital ptosis. J Egypt Ophthalmol Soc [serial online] 2017 [cited 2017 Oct 21];110:41-5. Available from: http://www.jeos.eg.net/text.asp?2017/110/2/41/211144


  Introduction Top


Congenital ptosis occurs because of levator muscle dystrophy in which the muscle and aponeurotic tissues appear to be infiltrated or replaced by fat and fibrous tissue [1]. Determining an appropriate surgical procedure for the correction of congenital ptosis should be individualized and obtaining ideal surgical outcomes can be both challenging and controversial [2]. The surgical procedure depends mainly on the levator muscle function and severity of ptosis [3]. There are several methods for surgical correction of ptosis, including levator muscle resection, the Fasanella–Servat procedure, and Muller muscle–conjunctival resection [4]. Although some advocate supramaximal levator resection in the setting of poor levator muscle function, others use frontalis sling surgery [5],[6]. Harris and Dortzbach [7] described transcutaneous levator tucking for the correction of blepharoptosis. Posterior approach blepharoptosis surgery, through the transconjunctival route, was probably the first technique used to shorten the levator muscle since Blaskovicz [8] first described it in 1923 with extensive dissection of the levator muscle from its surrounding structures before its resection. This was combined with a tarsectomy. Muller’s muscle–conjunctival resection is traditionally performed in patients with mild ptosis. In 1961, Fasanella and Servat [9] described their procedure for patients with minimal blepharoptosis. In this study, we evaluate the safety, and the anatomical and cosmetic outcomes of levator aponeurosis tucking using the posterior transconjunctival approach in cases of simple congenital ptosis.


  Patients and methods Top


Design

This was a prospective interventional noncomparative case-series study.

This study was carried out at the Ophthalmology Department of Minia University Hospital between January 2013 and July 2015. Thirty eyelids of 26 patients with simple congenital ptosis were included in this study. They were subjected to transconjunctival tucking of levator aponeurosis.

Inclusion criteria

Patients with simple congenital ptosis with fair to good levator muscle function (≥5 mm lid elevation) were included in this study.

Exclusion criteria

Patients with previous lid surgeries or trauma, the jaw-winking phenomenon, blepharophimosis syndrome, congenital myasthenia, myopathic or neurogenic disorders, and patients with absent Bell’s phenomenon were excluded from the study.

Preoperative evaluation

All patients were subjected to an assessment of history including onset, duration, variability, and progression. A full ophthalmological examination was performed. The degree of ptosis was evaluated using marginal reflex distance 1 (MRD1) measured as the vertical distance from the center of the pupil to the lower border of the upper eyelid. Evaluation of levator muscle function, with frontalis muscle immobilization, and assessment of Bell’s phenomenon were performed. Preoperative and postoperative photographs were taken for documentation.

Operative procedure

All surgeries were carried out under general anesthesia. The lid crease was marked and a traction suture of 6-0 silk suture was placed at the lid margin. The upper eyelid was everted over a Desmarres retractor. A mixture of 0.5–1 ml of 2% lidocaine with 1 : 100 000 adrenaline was injected subconjuctivally. A horizontal incision was made through the conjunctiva and Muller muscle ([Figure 1]a) at the upper tarsal margin. The conjunctiva and Muller muscle were dissected to expose the posterior surface of the levator apneurosis ([Figure 1]b and [Figure 1]c). The levator aponeurosis was plicated using two or three double-armed 6-0 vicryl sutures ([Figure 1]d) passed through its posterior surface to the tarsal plate passing through the entire thickness of the eyelid to be knotted on the skin at the level of lid crease ([Figure 1]e–[Figure 1]h).
Figure 1 Surgical steps: A: Conjunctival incision, B: Subconjunctival dissection, C: Exposure of levator, D: Levator plication, E to H: Suture application

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No tissue excision was performed in this procedure. Lid height was assessed and adjusted using temporary knots so that the upper eyelid margin rested at the limbus in cases with fair levator function (5–7 mm function) and 1 mm below the limbus in cases with good levator function (>7 mm function). The degree of tucking was 5/1 mm ptosis in cases with levator muscle function 5/1 mm, 4/1 mm ptosis in cases with levator muscle function 6–7 mm, and 3/1 mm ptosis in cases with levator muscle function greater than 7 mm. The amount of ptosis was calculated from the desired intraoperative position.

The incision of the conjunctiva and Muller’s muscle was left sutureless. The absorbable sutures were not removed and were left to dissolve spontaneously.

Postoperative care

A frost suture was placed in the lower lid margin to prevent exposure in the immediate postoperative period. The lid was dressed with betadine 10% and a mixture of steroid/antibiotic ointment was applied to the conjunctival sac, followed by a patching. Postoperative cold compresses were used to decrease postoperative edema. All patients were examined 1 day, 1 week, 1, and 6 months postoperatively.

Anatomical success was defined as eyelid margin position within 1 mm of the desired height (MRD1: 3 to 5 mm). All measurements were performed at the last postoperative visit. Cosmetic results were evaluated according to lid contour, symmetry in eyelid margin height, and lid crease appearance and symmetry ([Table 1]). Postoperative complications including postoperative edema, infection, lid margin malposition, and corneal exposure were evaluated.
Table 1 Cosmetic grading scale

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This study was approved by the local ethics committee and adhered to the tenets of the Declaration of Helsinki. Legal guardians of patients mean the parents of patients as all patients are children.

Statistical analysis

Data were collected and statistical analysis was carried out using IBM SPSS statistics (version 22; SPSS Inc., Chicago, Illinois, USA). Significance level was P-value less than or equal to 0.05.


  Results Top


There were a total of 24 patients, 14 (58.3%) females and 10 (41.7%) males. Eighteen (75%) patients had unilateral ptosis and six (25%) patients had bilateral ptosis. The age of the patients ranged between 4 and 14 years, with a mean of 7.4±3.04 years. The mean preoperative MRD1 was 2.2±0.6 mm, with a range of 1–3 mm. The levator muscle function ranged between 5 and 9 mm. The mean operative time was 23±4 min. The mean postoperative MRD1 was 4±0.8 mm, with a range of 2–5 mm. [Table 2] presents a comparison between preoperative and postoperative MDR1. Anatomical success was achieved in 26 (86.7%) eyelids. [Figure 2] and [Figure 3] show the preoperative and postoperative photos of patients with congenital ptosis. Undercorrection was present in four (13.3%) eyelids. No case of overcorrection was encountered. There was a clinically significant difference in preoperative MRD1 between the corrected and undercorrected cases, with P-value equal to 0.03 ([Table 3]). Undercorrection was associated with smaller MRD1, that is, more severe ptosis. Undercorrection was also related to less levator muscle function, P-value of 0.04 ([Table 4]). In terms of the cosmetic outcomes, good lid contour was present in 28 (93.3%) eyelids, acceptable in one (3.3%), and poor in one (3.3%) eyelid. Good symmetry of lid height was obtained in 22 (73.3%) lids and acceptable symmetry in six (20%) lids with poor symmetry in two (6.7%) lids. Good formed eyelid crease was present in 28 (93.3%) lids, with acceptable crease in two (6.7%) lids. Apart from undercorrection, no significant postoperative complications were encountered throughout the study. Mild to moderate lid edema and tenderness were present in all cases on the first postoperative day and resolved completely on the second evaluation visit after 1 week. Five (16.6%) cases developed trivial subconjunctival hemorrhage that disappeared by the end of the first week. No cases of infection, entropion, ectropion, or corneal exposure were present.
Table 2 Comparison between preoperative and postoperative marginal reflex distance 1

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Figure 2 Preoperative photos of two patients with congenital ptosis

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Figure 3 Postoperative photos of the two patients

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Table 3 Relation between undercorrection and preoperative marginal reflex distance

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Table 4 Relation between undercorrection and levator muscle function

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  Discussion Top


In this study, transconjunctival tucking of the levator aponeurosis was used for the treatment of congenital ptosis with fair to good levator muscle function. Patients with poor levator muscle function were not included as they require either frontalis sling surgery or supramaximal levator resection to achieve adequate ptosis correction. In this study, anatomical success was achieved in 26 (86.7%) eyelids of operated eyelids, whereas four (13.3%) eyelids developed undercorrection. A statistically significant difference was present between the preoperative and postoperative MRD1 (P=0.001). No case of overcorrection was present. Compared with skin side levator aponeurosis tucking, Abdelrahman [10] reported 17 corrected eyelids among 20 eyelids that were subjected to skin side levator aponeurosis tucking (85%), with undercorrection in two (10%) eyelids and overcorrection in one (5%) eyelid. Wang and Wang [11] compared levator muscle shortening and levator aponeurosis tucking in correcting congenital blepharoptosis. Twenty eyes were treated by each technique. With levator muscle shortening, 16 (80%) eyelids were corrected, three (15%) eyelids had undercorrection, and one (5%) had overcorrection. In patients treated with levator aponeurosis tucking, 16 (80%) eyelids were corrected whereas four (20%) lids had undercorrection of ptosis.

Chung et al. [12] used retrotarsal tucking of Muller muscle-levator aponeurosis for ptosis correction in conjunction with esthetic blepharoplasty in adult Asian eyelids. They used an external upper blepharoplasty approach with opening of the orbital septum and tucking of Muller muscle-levator aponeurosis under the posterior surface of the tarsus by a single lifting suture. In 26 patients (51 eyelids), they recorded satisfactory results for 49 of 51 (96.1%) eyelids. One of their patients had developed corneal irritation caused by the exposure to the tucking suture because of which the suture had to be removed in the patient.

Vrcek et al. [13] studied Muller’s muscle resection with conjunctival sparing in the management of mild to moderate ptosis. They achieved effective correction of ptosis with favorable cosmetic results and low postoperative complication on preserving the conjunctiva.

Al-Abbadi et al. [14] described a similar procedure of transconjunctival levator plication under the term posterior levatorpexy is a medical term meaning tucking of the levator muscle through posterior approach. They operated on 19 lids of 16 patients with congenital ptosis. The mean preoperative MRD1 was 1.5 mm (range: −1 to 3 mm) and the mean postoperative MRD1 was 2.6 mm (range: 1–4.5 mm). They achieved a success rate of 87%. Our outcomes are in agreement with this result, although the definition of anatomical success is different between the two studies.

In transconjunctival tucking, there is no skin incision, with no risk of an external scar and no severing of the attachments of the levator aponeurosis to the overlying orbicularis muscle. The orbital septum is not opened, and there is no dissection of preaponeurotic fat from the underlying levator aponeurosis and the levator horns are left intact. This leads to minimal disturbance of the normal anatomy. Moreover, there is no excision of the conjunctiva with preservation of goblet cells. The dissection of conjunctiva and Muller’s muscle together avoids conjunctival buttonhole formation and provides a relatively thick layer that covers the tucking sutures during postoperative healing with no suture-related corneal complications. The procedure is less time consuming compared with other ptosis-correction procedures with no special instrumentation and less use of sutures.

The main limitation of the study is that a relatively longer follow-up period was needed to assess the long-term efficacy of the procedure and the stability of the postoperative results.

Transconjunctival tucking of the levator aponeurosis is a safe and effective procedure for correction of simple congenital blepharoptosis, with favorable cosmetic outcomes. A higher success rate may be achieved on selecting cases with mild to moderate ptosis and cases with fair to good levator muscle function.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Wabbels B, Schroeder JA, Voll B, Siegmund H, Lorenz B. Electron microscopic findings in levator muscle biopsies of patients with isolated congenital or acquired ptosis. Graefes Arch Clin Exp Ophthalmol 2007; 245:1533–1541.  Back to cited text no. 1
    
2.
Mokhtarzadeh A, Harrison AR. Controversies and advances in the management of congenital ptosis. Expert Rev Ophthalmol 2015; 10:59–63.  Back to cited text no. 2
    
3.
Allard FD, Durairaj VD. Current techniques in surgical correction of congenital ptosis. Middle East Afr J Ophthalmol 2010; 17:129–133.  Back to cited text no. 3
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4.
Baroody M, Holds JB, Vick VL. Advances in the diagnosis and treatment of ptosis. Curr Opin Ophthalmol 2005; 16:351–355.  Back to cited text no. 4
    
5.
Takahashi Y, Leibovitch I, Kakizaki H. Frontalis suspension surgery in upper eyelid blepharoptosis. Open Ophthalmol J 2010; 4:91–97.  Back to cited text no. 5
    
6.
Mokhtarzadeh A, Harrison A. Controversies and advances in the management of congenital ptosis. Expert Rev Ophthalmol 2015; 10:59–63.  Back to cited text no. 6
    
7.
Harris W, Dortzbach R. Levator tuck. A simplified blepharoptosis procedure. Ann Ophthalmol 1975; 7:873–878.  Back to cited text no. 7
    
8.
Blaskovicz L. A new operation for ptosis with shortening of the levator and tarsus. Arch Ophthalmol 1923; 52:563–573.  Back to cited text no. 8
    
9.
Fasanella RM, Servat J. Levator resection for minimal ptosis: another simplified operation. Arch Ophthalmol 1961; 5:493.  Back to cited text no. 9
    
10.
Abdelrahman R. The efficacy of levator tucking in management of congenital ptosis. J Egypt Ophthalmol Soc 2012; 105:153–160.  Back to cited text no. 10
    
11.
Wang C, Wang Y. Comparison of surgical efficacy of levator muscle shortening and modified levator aponeurosis tucking in treating minimal and moderate congenital blepharoptosis. Eye Sci 2015; 30:29–30.  Back to cited text no. 11
    
12.
Chung S, Ahn B, Yang W, Burm J, Kim K, Kang S. Borderline to moderate blepharoptosis correction using retrotarsal tucking of Müller muscle: levator aponeurosis in Asian eyelids. Aesthetic Plast Surg 2015; 39:17–24.  Back to cited text no. 12
    
13.
Vrcek I, Hogan R, Rossen J, Mancini R. Conjunctiva-sparing posterior ptosis surgery: a novel approach. Ophthal Plast Reconstr Surg. 2016; 32:366–370.  Back to cited text no. 13
    
14.
Al-Abbadi Z, Sagil S, Malhorta R. Outcomes of posterior-approach ‘levatorpexy’ in congenital ptosis repair. Br J Ophthalmol 2014; 98:1686–1690.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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