Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009

Congenital Ptosis: Evaluation and Management 169

Xylocaine with adrenaline is used for local anesthesia in adults but general anesthesia is necessary for children.

Surgical Steps (Figures 9A to E)

Eyelid is everted and tarsal plate is exposed. Three sutures are passed close to the folded superior margin of the tarsal plate at the junction of middle, lateral and medial one third of the lid. Three corresponding sutures are placed close to the everted lid margin starting from conjunctival aspect near the superior fornix in positions corresponding to the first 3 sutures. Proposed incision is marked on the tarsal plate such that a uniform piece of tarsus, decreasing gradually towards the periphery is excised. This is necessary to avoid the central peaking. A groove is made on the marked line of incision and the incision is completed with the scissors. The first set of sutures help in lifting the tarsal plate for excision. The second set aids suturing by lifting and supporting conjunctival and tarsal edges during suturing. The tarsal plate not more than 3 mm in width is excised.

5-0 plain catgut is used for continuous suturing and the knot is buried within the wound. Postoperatively the patients are kept on antibiotics and antiinflammatory agents and cornea is observed for any sign of abrasion.

The preoperative and postoperative photographs of a patient taken up for Fasanella servat surgery in the primary, up and down gaze are shown in Figures 10A to F.

Complications of Fasanella Servat Surgery

1.Under or overcorrection—If the lid is too low then reoperate. If the lid is too high, in early postoperative traction might help otherwise reoperate.

2.Dry eye—Surgery should be avoided in patients with dry eye symptoms as the procedure removes some of the

172 Oculoplasty and Reconstructive Surgery

well as the amount of skin show measured in the primary position. In bilateral cases highest forming crease is used which is usually at the superior border of the tarsus or standard measurements can be used.

Three 4-0 silk sutures are passed near the lid margin to provide traction. A lid spatula is placed under the lid and incision through the skin and orbicularis made along the crease marking (Figure 11A). The inferior skin and orbicularis are dissected away from the tarsal plate (Figure 11B). The upper edge is separated from the orbital septum (Figure 11C). The orbital septum is cut completely across exposing the preaponeurotic fat (Figure 11D). Fat is retracted posteriorly exposing the whole tendinous aponeurosis (Figure 11E). Three partial thickness traction 4-0 silk suture are passed through the distal end of the aponeurosis. The fibers of the aponeurosis are cut from their insertion in the inferior half of the anterior surface of the tarsus (Figure 11F). The levator is freed from the adjoining structures. The lateral and the medial horn are cut (Figure 11G). The direction of the cut should be vertical to avoid damage to the lacrimal gland laterally or the pulley of superior oblique muscle medially. Care should be taken that Whitnalls ligament is not damaged which is visualized as a whitish fascial condensation running across the junction of the muscular and aponeurotic part of the levator about 15 mm from the insertion. A double armed 5-0 vicryl is passed through the centre of the tarsal plate by a partial thickness bite. It is then passed through levator aponeurosis and intraoperative assessment is made(Figure 11H). Two more double armed vicryl 5-0 sutures are passed through the tarsus about 2 mm from the upper border in the center and at the junction of central third with the medial and lateral thirds (Figure 11I). These sutures are then placed in

Congenital Ptosis: Evaluation and Management 175

The position of the lid aimed at during the table assessment should be as follows:

•Patients are prescribed oral antibiotics and antiinflammatory agents.

Preoperative and postoperative photographs are demonstrated in Figures 12A to F.

Complications of Levator Surgery

1.Undercorrection: Multiple factors may be responsible for undercorrection (Figure 13), It may either be due to inadequate resection of levator or due to a thin friable or fibrotic levator muscle associated with poor levator action where even a large levator resection may prove inadequate. In these cases even where a good correction is achieved in early postoperative period, there may be a late development of drooping in a few months time. The surgeon should wait for a couple of months before considering for re-surgery.

2.Overcorrection: Overcorrection may be due to too large a resection of the levator or due to advancement of the levator too far down on the tarsus (Figure 14).

Massage and traction on the lashes can be tried in the early postoperative phase. But in late phase tarsotomy, levator recession or recession with a spacer such as scleral graft is required depending on the amount of overcorrection.