Ординатура / Офтальмология / Английские материалы / Oculoplasty and Reconstructive Surgery Made Easy_Garg,Touky, Nasralla_2009
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Congenital Ptosis: Evaluation and Management 189
6.Exposure keratitis: Requires use of lubricants and patching at night.
7.Granuloma formation: This is commoner with synthetic material (Figure 29)
8.Infection: Infection either early or later may occur. This is commoner with synthetic material. Infection is rare with use of autogenous fascia lata (Figure 30).
Figure 29: Showing suture granuloma with synthetic material
Figure 30: Infection following sling surgery, more common with synthetic material
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MANAGEMENT OF COMPLICATED PTOSIS
Ptosis with Oculomotor Abnormalities
It is necessary to correct the ocular motility problem before correction of ptosis because the restriction of the superior rectus and accompanying hypotropia makes the assessment of ptosis difficult. Secondly, the hypotropic eye with poor Bell’s penomenon is extremely vulnerable to exposure keratopathy due to postoperative lagophthalmos.
Congenital Ptosis with Superior Rectus Weakness
Superior weakness is a common association as both muscles develop from the same myotome. The hypotropia is corrected by an inferior rectus recession at times combined with superior rectus resection as the first procedure. Ptosis correction is then carried out using the procedure indicated by evaluation.
Ptosis Associated with Double Elevator Palsy
Knapps procedure may be done for ptosis associated with double elevator palsy. The lateral and medial rectus tendons are transposed to the sides of superior rectus insertion. This does not cause significant limitation of adduction or abduction. Ptosis is corrected 3 months later.
Blepharophimosis Syndrome
The blepharophimosis syndrome comprises of ptosis, epicanthus inversus, telecanthus, horizontal shortening of palpebral aperture, flattened supraorbital ridges, arching of the eyebrow and lateral ectropion of the lower eyelid.
•Mustarde’s double “Z” plasty or Y-V plasty with transnasal wiring is done as a primary procedure. This gives a good surgical result both in terms of correction of telecanthus as
Congenital Ptosis: Evaluation and Management 191
well as deep placement of the medial canthus. The results are long lasting.
•Brow suspension is carried out 6 months after the first procedure for correction of ptosis.
Double Z Plasty or Y to V Plasty with Transnasal Wiring
Lateral canthotomy and canthoplasty may be carried out before the skin incision is made.
The markings for double Z plasty are made as shown in Figure 31. The first mark is made just medial to the medial canthus (A). The proposed canthal site (B) is marked such that intermedial canthal distance is half that of interpupillary distance. The two marks are joined. All the other lines drawn are 2 mm smaller than the line AB. Two lines are drawn from A parallel to upper and lower lid margins. From the centre point of AB(C), a line is drawn medially at 60° both above and below ( CD). Another line is drawn outwards at an angle of 45° from the point of D ( DE).
The markings for Y-V plasty are shown in Figure 32A. The incision are made through the skin down the to the orbicularis. The flaps are undermind (Figure 32B). The site of proposed canthus is cleared of all tissue upto the periosteum and the medial palpebral ligament is exposed. The periosteum is incised medial to the insertion of MPL and is reflected along with the lacrimal sac.
Figure 31:Z-plasty
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Figures 32A and B: (A) Markings of Y-V plasty. (B) Incision given and flap undermined
A large bony opening 12-15 mm high and 10-12 mm wide is made as for dacryocystorhinostomy but located more posterior and superior. The edges of the bony opening are smoothened. A similar procedure is performed on the opposite side.
Medial palpebral ligament (MPL) of one side is wired with 24 G stainless steel wire close to its attachment to the tarsus and the two ends of the wire are passed to the opposite side through the bony opening with the aid of an aneurysm needle or a Wright’s fascia lata needle. The wire is threaded into the opposite MPL by a similar double bite. The two ends are tightened and a single twist given to the wires (Figure 33). The position of the medial canthus is assessed from the front, above and the sides. Once the desired position is obtained the wire is twisted several times and cut. The ends of the wire are pushed into the bony opening. After achieving the hemostasis the incision is closed in several layers. The skin flaps may need to be trimmed before they are tranposed and sutured with 6-0 silk (Figure 34).
Lateral Canthoplasty
Thee lateral canthus is crushed by a straight hemostat for a few seconds. A lateral canthotomy is performed. The bulbar
Congenital Ptosis: Evaluation and Management 193
Figure 33:Transnasal wiring
Figure 34: Skin sutured
conjunctiva at the lateral canthus is undermined. The apex of the conjunctiva is sutured to the proposed new position of the canthus which is short of the end of the skin incision. The skin edges distal to the new lateral canthus are apposed with 6-0 silk sutures. The similar procedure is repeated on other side.
The bandage is removed after 24 hrs and sutures are removed between 5-7 days.
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Stage II
The second stage is performed after 6 months. A bilateral fascia lata sling is performed.
Figures 35A to C shows the preoperative photograph of a patient with Blepharophimosis syndrome after stage 1 and 2 procedure.
Marcus Gunn Ptosis
Ptosis associated with lid retraction on opening the jaw or its movement to the opposite side is classical marcus gunn phenomenon. An inverse Marcus Gunn phenomenon is also known.
Management depends on the cosmetic significance of the jaw winking. Where jaw winking is not significant the choice
Figures 35A to C: (A) A patient with blepharophimosis syndrome.
(B)Postoperative photograph following Y-V plasty and transnasal wiring.
(C)Postoperative photograph following fascia lata sling surgery
Congenital Ptosis: Evaluation and Management 195
of procedure depends on the amount of ptosis and the levator action, as in any case of congenital simple ptosis. A larger levator resection is necessary and undercorrection is common. In case with significant jaw winking bilateral levator excision with a fascia lata sling surgery is the procedure of choice
(Figures 36A to D).
Figures 36A to D: (A) A patient with moderate ptosis with Marcus Gunn phenomenon. (B) Postoperative photograph following bilateral levator excision with fascia lata sling surgery. (C) Marcus Gunn phenomenon elicited on opening of mouth. (D) Postoperative photograph. Marcus Gunn phenomena is eliminated
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Misdirected Third Nerve Ptosis
•In cases of misdirected third nerve ptosis where treatment is indicated levator excision with bilateral fascia lata sling is the procedure of choice.
•Ptosis associated with third nerve palsy is difficult to manage because of poor Bell’s phenomenon. A crutch glass may be prescribed or a conservative sling surgery may be performed.
BIBLIOGRAPHY
1.Beard C. Ptosis, 3rd edition. St. Louis : CV Mosby Company 1981.
2.Berke RN. Types of operation for congenital and acquired ptosis – In Trauotman R, Converse J, Smith B (Editors): In Plastic and reconstructive surgery of the eye and adenexa. Washington DC Butterworths 1962.
3.Betharia SM, Grover AK, Kalra BR. Br J Ophthalmol. 1983;67:58-60.
4.Crawford JS. “Congenital Blepharoptosis” in Bryon C Smith - Ophthalmic Plastic and reconstructive surgery. Vol. 1, CV Mosby Company, 1987:631-53.
5.Crawford JS. Congenital Blepharoptosis in Byron C. Smith Ophthalmic plastic and reconstructive surgery, Vol. 1, CV Mosby Company 1987:631-53.
6.Grover AK, Gupta AK. Proceedings of the Golden Jubilee Conference of All India Ophthalmological Society, New Delhi 1992:54-56.
7.Grover AK, K Uma Chaturvedi, Sanjal Mittal. Presented at 53 AIOS Annual Conference at Bombay 1995.
8.Grover AK, Mittal Sanjay. A Clinico-pathological study of levator muscle for Congenital Ptosis. Thesis is submitted to Delhi University.
9.Gunn RM. Trans Ophthal Soc UK 1983;3:283.
10.Mustarde JC. Epicanthus and telecanthus. Int Ophthalmol Cli 4:1964.
11.Putterman. Basis oculoplastic surgery in Peyman GA: Principles and practice of ophthalmology, Vol. 3. Philadiphia: WB Saunders Company 1980:2246-33.
12.Smith B, McCord CD, Baylis H. Am J Ophthalmol 1969;68:92.
INTRODUCTION
Ptosis or dropping of the upper eyelid, is the most common lid malposition encountered in clinical practice in both adults and children population and is the most surgically correctable lid disorder.
The upper lid position is a function of the delicate balance between the lid retractors including levator muscle, Muller’s muscle, and frontalis muscle, and the lid protractors including the orbital pat and palpebral part of the orbicularis oculi muscle. Normally the upper lid covers the upper 1-2 mm of the cornea in the primary position, providing no obstacle to image formation on the retina. It follows the globe on looking down with no lag. It provides complete coverage of the eye on lid closure. Finally, it rises up for up to 20 mm in extreme up-gaze.
Changingtheactivityofthelevator,Muller’smuscles,bring all of these movements about. The frontalis muscles are called into action only in extreme up-gaze. The orbicularis muscle in mainly used in forceful lid closure although its palpebral part shares in the blinking mechanisms.
Both upper eyelids are symmetrical. The brain considers both lid retractor as yoke muscle. They receive equal innervationsformsinglesubdivisionoftheoculomotornucleus
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in the midbrain. Changes in the position of one lid will lead to affection of the position of the other in a similar fashion to the secondary changes occurring in extraocular muscle when its yoke muscle is weak, paralyzed or overacting.
A successful ptosis surgery provide a lid that is at or just below the limbus in the primary position and moves freely with the globe in up and down gaze. This result can be obtained only in mild to moderate degrees of ptosis when levator muscle can be attempted successfully.
However, when the levator function is poor (less than 4 mm), Frontalis muscle surgery has long been accepted as the best technique for managing the blepharoptosis. In these cases if levator muscle surgery is attempted, then In order to position the lid at an acceptable level, at least 25 mm or more of the levator muscle should be resected. This would entail cutting of both levator horns as well as the advancement of Whitnall’s ligament and its suturing to the anterior surface of the tarsus.
The results are usually less than acceptable with a lid that is so shortened to be practically immobile or frozen. Lagophthalmos is invitable and corneal exposure is considered the major postoperative complication and occurres in over 75% of patients. In unilateral cases, marked asymmetry between both lids is noted. Most surgeons conclude that good results are seldom achieved with this procedure in poor levator function cases and recommend frontalis muscle surgery instead.
THE MECHANISM OF LID ELEVATION
AFTER BROW SUSPENSION
The upper eyelid is suspended from the brow so the patient opens the eye by the brow and closes the eye by orbicularis