References

1.Putterman AM, Urist M. Müller’s muscle-conjuncti- val resection: technique for treatment of blepharoptosis. Arch Ophthalmol. 1975;93:619–23.

2.Cohen AJ, Weinberg DA. Müller’s muscle-conjuncti- val resection for blepharoptosis with poor levator function. Ophthalmic Surg Lasers. 2002;33:491–2.

3.Georgescu D, Epstein G, Fountain T, Migliori M, Mannor G, Weinberg D. Müller’s muscle conjunctival resection for blepharoptosis in patients with poor to fair levator function. Ophthalmic Surg Lasers Imaging. 2009;40(6):597–9.

4.Cohen AJ, Mercandetti M. Ptosis, adult.eMedicine from WebMD. http://emedicine.medscape.com/ article/1212082-overview. Accessed 18 Nov 2009.

5.Cohen AJ, Bernstein JA. Müller’s muscle-conjuncti- val resection for blepharoptosis repair. Techniques in ophthalmology. 2002;33(6):`491–2.

6.Yazici B. Use of 0.5% aproclonindine solution in evaluation of blepharoptosis. Ophthal Plast Reconstr Surg. 2008;24(2):299–301.

7.Glatt HJ, Fett DR, Putermann AM. Comparison of 2.5% and 10% phenylephrine in the elevation of upper eyelids with ptosis. Ophthalmic Surg. 1990; 21(3):173–6.

8.Miller SA, Mieler WF. Systemic reactions to subconjunctival phenylephrine. Can J Ophthalmol. 1978; 13(4):290–3.

9.Baldwin HC, Bhagey J, Khooshabeh R. Open sky Müller muscle-conjunctival resection in phenylephrine test-negative blepharoptosis patients. Ophthal Plast Reconstr Surg. 2005;21(4):276–80.

10.Fraunfelder FW, Fraunfelder FT, Jensvold B. Adverse systemic effects from pledgets of ocular topical phenylephrine 10%. Am J Ophthalmol. 2002;134(4): 624–5.

11.Putterman AM, Fett DR. Müller’s muscle in the treatment­ of upper eyelid ptosis; a ten year study. Ophthalmic Surg. 1986;17:354–60.

12.Weinstein GS, Buerger GF. Modification of the Müller’s muscle-conjunctival resection operation for blepharoptosis. Am J Ophthalmol. 1982;93(5):647–51.

13.Dresner SC. Further modifications of the Müller’s mus- cle-conjunctival resection procedure for blepharoptosis. Ophthal Plast Reconstr Surg. 1991;7:114–22.

14.Mercandetti M, Putterman AM, Cohen ME, Mirante JP, Cohen AJ. Internal levator advancement by Müller’s muscle-conjunctival resection: technique and review. Arch Facial Plast Surg. 2001;3(2):104–10.

15.Perry JD, Kadakia A, Foster JA. A new algorithm using conjunctival Müller’s muscle resection with or without tarsectomy. Ophthal Plast Reconstr Surg. 2002;18(6):426–29.

16.Ben Simon GJ, Lee S, Schwarcz RM, McCann JD, Goldberg RA. Müller’s muscle-conjunctival resection for correction of upper eyelid ptosis. Arch Facial Plast Surg. 2007;9(6):413–17.

17.Ayala E, Galvez C, Gonzalez-Candial M, Medel R. Predictability of conjunctival-müllerectomy for blepharoptosis repair. Orbit. 2007;26:217–22.

18.Cohen AJ. Oculoplastic and orbital surgery. Ophthalmol Clin North Am. 2006;19(2):257–67.

19.Georgescu D, Cole E, Epstein G, Fountain T, Migliori M, Nguyen Q, et al. Müller muscle-conjunctiva resection for blepharoptosis in patients with glaucoma filtering blebs. Ophthal Plast Reconstr Surg. 2007;23: 285–7.

20.Michels KS, Vagefi MR, Steele E, Zwick OM, Torres JJ, Seiff SR, et al. Müller muscle-conjunctiva resection to correct ptosis in high-risk patients. Ophthal Plast Reconstr Surg. 2007;23:363–6.

21.Dailey RA, Saulny SM, Sullivan SA. Müller’s mus- cle-conjunctival resection-effect on tear production. Ophthal Plast Reconstr Surg. 2002;18(6):421–25.

Abstract  Aponeurotic blepharoptosis may be safely and effectively corrected by resection of Müller’s muscle. This surgery is thought to raise the upper lid by advancement of the levator muscle and aponeurosis. A particular feature of the technique is a consistently good postoperative eyelid contour, achieved through high placement of sutures on the tarsal plate. The open-sky technique offers advantages over other ptosis surgeries, including direct visualization of Müller’s muscle, opportunity for adjustment of lid height, the potential for preservation of conjunctival tissue, and efficacy in patients who do not demonstrate a positive phenylephrine test.

Introduction

Müller’s muscle is a small smooth muscle arising from the striated levator muscle along with the aponeurosis at or slightly above the level of the superior fornix. The body of Müller’s muscle extends forward and downward for about 10 mm, enclosed in a rich vascular sheath. It is firmly attached to the conjunctiva, but easily separated from the aponeurosis. Its nerve supply is from the cervical sympathetic chain. The muscle helps to maintain the tone of the raised eyelids, contributing to the final 2 mm of lid elevation. This is based on clinical observation of patients with

H. Baldwin (*)

Princess Margaret Hospital Windsor, UK e-mail: heathercbaldwin@hotmail.com

Horner’s syndrome who are often found to have a mild ptosis of around 2 mm.

Müller’s muscle inserts onto the upper border of the tarsal plate through a 0.5–1.5 mm tendon. The attachment of the levator aponeurosis to the tarsal plate is less well defined. It has been proposed that aponeurosis fibers insert into the anterior surface of the tarsal plate, as well as into orbicularis fibers forming the skin crease. Proponents of this theory support the aponeurosis as the main transmitter of levator contraction and, therefore, principally responsible for eyelid height [1, 2]. Based on this theory, traditional techniques for the correction of ptosis use aponeurosis advancement or resection to elevate the lid. By contrast, others propose that the levator aponeurosis ends blindly in a transverse ridge 2–3 mm above the tarsal plate [3–5], and that the aponeurosis supports the skin, the orbicularis, and the lashes, whereas the main upward pull of the tarsal plate is relayed by Müller’s muscle. An extrapolation of this proposal is that Müller’s muscle may be acting as a spindle in a stretch reflex [6].

These theories place emphasis on the role of Müller’s muscle in determining eyelid height, and support the option of Müller’s muscle resection for the correction of ptosis. Since a strip of muscle remains in place, there is preservation and even augmentation of changes in eyelid height associated with emotion and other autonomically mediated facial expressions.

Correction of blepharoptosis using Müller’s muscle-conjunctival resection was originally described by Putterman, who used a modified clamp designed for the Fasanella–Servat procedure.

He bluntly separated the conjunctiva and Müller’s muscle from the underlying levator aponeurosis by a posterior approach [7]. Müller’s muscleconjunctival resection has been reported to give excellent results in terms of adequate and predictable lid elevation and contour [7–15]. This chapter describes a modification of this technique, in which direct visualization of Müller’s muscle is obtained before its dissection and resection, and sutures are passed through the skin crease [16–18].

The wound is dressed according to the surgeon’s­ preference, and if silk sutures are used, they may be removed between 5 and 21 days postoperatively. If the lid margin is on or above the upper limbus, the sutures may be removed in the earlier stages and a regime of lash traction three times daily is applied; if below the limbus, the sutures may be removed later.

Surgical Technique

As with all the surgeries to correct blepharoptosis, this procedure may be carried out under local anaesthesia or general anaesthesia, and the considerations taken into account are the same. When local anesthesia is employed, adrenaline may be omitted to avoid stimulation of Müller’s muscle, thereby influencing the height of the eyelid. Minimal amounts are injected to avoid tissue distortion. The skin crease is marked, and any excess skin is removed if a simultaneous blepharoplasty is being performed. Next the lid is everted over a Desmarres retractor. This may be held in place by traction using a lid margin suture. On the posterior lid surface, an incision is made along the upper border of the tarsal plate and then Müller’s muscle and conjunctiva are lifted together from the levator aponeurosis. A subtotal resection of the conjunctiva and Müller’s muscle is performed, preserving a 1–2 mm stump of Müller’s muscle. Three double-ended 5/0 silk sutures are passed through the cut edge of forniceal conjunctiva, Müller’s muscle, and the upper border of the tarsal plate, and finally through the skin crease marked at the beginning of the operation. The first suture is placed at the midpoint of the lid over the pupil, slightly medially in adults, and the other two sutures are placed at approximately equal distances on each side, 3–5 mm from the middle suture, but adjusted according to the age of the patient and the lid contour on the table. The central suture is tied in a loop so that the lid height may be assessed and adjusted as needed. The other two sutures are tied after assessment of the lid contour.

Preservation of the Conjunctiva

A modification of the open-sky technique involves resection of Müller’s muscle alone (Fig. 20.1), thereby preserving healthy conjunctival tissue in its anatomical position [18]. It may be desirable to preserve healthy conjunctival tissue for two principal reasons. First, concern has previously been raised that excision of part of the tarsal conjunctiva, and therefore a proportion of goblet cells, might lead to dry eyes following this procedure. In fact, it appears that none of the elements necessary for a healthy tear film, including mucin secretors (goblet cells), lacrimal secretors (accessory lacrimal glands), and lipid secretors (meibomian glands), are significantly affected [19]. However, there are no long-term follow-up data available, and it may be that their tear film could be compromised in later years. Patients with a history of dry eye are traditionally thought to be unsuitable for Müller’s muscle–conjunctival resection, but may be able to benefit from the same procedure with preservation of the conjunctiva. The preservation of the conjunctiva also has anatomical advantages. Although Putterman has reported safe use of his technique in 35 anophthalmic patients [11], preservation of conjunctiva would decrease the risk of fornix shallowing in these patients.

In order to use this modification, the conjunctiva and Müller’s muscle are incised just above the upper border of the tarsal plate. The plane between Müller’s muscle and the levator aponeurosis is identified, and blunt dissection on this plane is extended upward until a rolled white band is seen (folded aponeurosis). Müller’s muscle is then lifted off the conjunctiva up to the level of the fornix. At this stage, a subtotal Müller’s muscle resection is performed, leaving a 2–3 mm stump,

Fig. 20.1  Surgical technique for isolated (conjunctivasparing) Müller muscle resection. (a) The lid is everted, and conjunctiva and Müller’s muscle incised just above the upper border of the tarsal plate. (b) Blunt dissection is performed

in the plane between Müller’s muscle and the levator aponeurosis. (c) Müller’s muscle is lifted off the conjunctiva up to the level of the fornix. (d) A subtotal Müller’s muscle resection is performed, leaving a 2–3 mm stump

as in the technique described above. A doubleended 5/0 silk suture is placed through the conjunctiva at the level of the initial incision, through the stump of Müller’s muscle, through the upper border of the tarsal plate, and finally out through the marked skin crease. This suture is tied on a loop, and eyelid height and contour checked. Two further sutures are placed through the same structures medially and laterally, and also tied on loops. Height and contour are then checked before tying the sutures on the skin crease.

Open-Sky Müller’s Muscle Resection

and the Phenylephrine Test

Müller’s muscle is an unusual smooth muscle due to its innervation by the sympathetic rather than the parasympathetic nervous system. It is therefore susceptible to stimulation by phenylephrine,

a direct-acting alpha-1 adrenergic agonist. Interestingly, however, alpha-2 receptors have been found to be the predominant adrenergic receptors in Müller’s muscle, and beta-1 receptor subtypes predominant in the levator muscle [20]. This raises the question of whether the phenylephrine test allows a complete representation of Müller muscle action; it is probably accurate for alpha-1 receptors, but it does not include assessment of alpha-2 receptors.

A positive phenylephrine test has traditionally been used as an indication that resection of Müller’s muscle will raise the lid margin. Topical applications of phenylephrine have been used in either the 2.5% or 10% preparations [7, 8, 10–12, 21]. Phenylephrine is a direct acting sympathomimetic drug that stimulates the sympathetic innervation of Müller’s muscle, causing it to contract and shorten, thereby elevating the eyelid. The degree of elevation produced by the topical