Ptosis Correction

Anatomy and Physiology

The opening located between the upper and lower eyelid is elliptical and termed the palpebral fissure. The upper eyelid curvature is maximum at a point just nasal to the mid pupillary point, which is an important point to mark before surgery to get the best cosmetic results. The upper lid covers 1 to 2mm of the superior limbus, while the lower lid lies at the lower limbus. 

Structures forming the eyelid[5]

1. Skin and subcutaneous tissue
2. Orbicularis oculi
3. Orbital septum
4. Preaponeurotic fat pad
5. Tarsal plate
6. Levator aponeurosis and Muller’s muscle
7. Conjunctiva

Skin

The eyelid skin is the thinnest layer of skin in the entire body. The eyelid crease forms due to attachment of levator aponeurosis to the skin.

Orbicularis oculi

It is a circular muscle and consists of three parts namely: preseptal, pretarsal, and orbital orbicularis. Contraction is responsible for gentle and forced closure of the eyelid. 

Orbital septum

It is a multi-layered structure of thin fibrous connective tissue. The septum inserts superiorly to the periosteum over the superior orbital rim. Inferiorly it merges with the fibers of levator aponeurosis above the superior tarsal border.[5]

In ptosis surgery, the septum is opened to gain access to the levator muscle. Care should be taken to separate septal attachments to the levator muscle to avoid post-operative lid retraction. 

Preaponeurotic fat pad

The fat pad is posterior to the septum and anterior to the levator. This pad of fat can be identified intraoperatively by applying pressure over the globe which causes it to prolapse forward. It helps in identifying the levator muscle which lies immediately posterior to it. 

Tarsal plate

Tarsal plate forms the structural skeleton of the eyelid and is made up of dense connective tissue. The vertical height is 10 to 12 mm in the upper eyelid and 4 to 5 mm in the lower lid. The tarsal plates contain the Meibomian glands, the orifices of which open posterior to the grey line. 

Levator Palpebrae superioris muscle (LPS)

LPS is the main elevator of the eyelid. It originates at the orbital apex from the periosteum over the lesser wing of sphenoid. It travels forward below the roof of the orbit. At the superior orbital rim, it changes direction from horizontal to vertical and forms the tendinous sheath called levator aponeurosis. At this transition, lies the Whitnall’s ligament which is seen as a dense white band of connective tissue and acts as a pulley. It lies 10 to 12 mm above the tarsal plate.

The levator aponeurosis has several insertions. Anteriorly, it inserts into the upper lid skin forming the lid crease. Inferiorly, it inserts onto the anterior surface of the superior one-third of the tarsus. Posteriorly, it has attachments to the superior conjunctival fornix. Medially and laterally, it forms the medial and lateral horns which then insert into the posterior lacrimal crest and Whitnall’s tubercle along with the canthal tendons.[6]

The levator receives nerve supply by the superior division of the oculomotor nerve. 

Muller’s muscle

It is a sympathetically innervated smooth muscle. It originates from the under surface of the levator aponeurosis at the level of the Whitnall ligament and inserts into the superior border of the tarsus. It contributes to 2 mm of eyelid elevation. 

Conjunctiva

It is the innermost layer of the eyelid formed by non-keratinizing squamous epithelium. It continues over the anterior surface of the globe. It contains goblet cells, the secretions of which hour of utmost importance in keeping the eyes moist.

Indications

Most patients undergoing ptosis correction seek surgery due to visual obscuration and loss of peripheral field of vision caused by the drooping eyelid. Heaviness in the eyelids is another common concern. A significant proportion seeks surgery for cosmetic concern as the drooping eyelid creates a tired-looking appearance.

Contraindications

1. Severe dry eye
2. Patients suffering from myogenic ptosis like chronic progressive external ophthalmoplegia - in these patients, if ptosis correction is planned, a conservative surgery should be the choice to clear  the visual axis
3. Poor Bell’s phenomenon
4. Ptosis associated with oculomotor nerve palsy
5. Myasthenia gravis: These patients should be treated medically first with anticholinesterase agents

Equipment

A basic oculoplasty instrument set, local anesthetic containing epinephrine, a skin marking pen and measuring scale is all that is needed to perform a successful ptosis surgery.

Preparation

A thorough pre-operative evaluation which includes a detailed history and meticulous clinical investigation helps improve the surgical success of ptosis surgery. 

Patient counseling and consent

A patient should clear explanation about the goals of surgery, including the surgical technique used, incision size, and nature of postoperative scar. The surgeon should show the patient pre- and post-operative photographs of other patients, so they know what to expect. Patients undergoing a conservative approach should be shown in the clinic, the amount of lid lift. Patients need to understand about the possibility of overcorrection, under-correction, lid contour asymmetry, post-operative lagophthalmos, dry eyes, exposure keratopathy, wound infection, recurrence of drooping post-surgery and informed consent obtained. 

Pre-operative photographs

Clinical photographs are taken with flash in the following gazes:

1. Straight gaze
2. Closed eyelids
3. Downgaze
4. Upgaze
5. Oblique view

Pictures are then taken two months post-surgery in the same positions for comparison.

Technique or Treatment

A brief history of ptosis surgery:

Early treatments for ptosis involved excision of the excess skin on the upper eyelid. The earliest description of suspension of the eyelid to the brow with absorbable catgut sutures was made by Dransart in 1880. This was modified by Pagenstecher who suspended the eyelid skin to the brow with silk sutures. Wright (1922) and Crawford (1956) attempted the use of the fascia lata as a sling, by attaching it to the tarsal plate and anchoring it to the frontalis muscle.[7] Other autologous materials that were tried are palmaris tendon and temporalis fascia. Subsequently, nonabsorbable sutures have also been tried as a sling. Tillet and Tillet (1966) recommended the use of silicone rod slings.[8] They have claimed that the better elasticity provided by their modified silicone rods lead to a significant reduction in the lagophthalmos associated with ptosis.

Levator resection, initially carried out through the conjunctival route, was introduced by Bowman in 1857, and later developed by Blaskovics (1909).  It was further improved by Berke and Illif. Berke (1959) is credited with evolving the levator function technique to decide the intraoperative lid height which is a useful guide during surgery.[9]

Everbush (1883) and Wolf (1896) popularized the anterior or skin approach for ptosis correction. In their opinion, it is a more efficient approach to the identification of the levator aponeurosis, and a larger area of the aponeurosis can be excised using this approach. Also, as the anatomy is easier to understand, it is easier to perform for novice surgeons.

Fasanella and Servat in 1961 described a simple vertical lid shortening procedure for correcting mild ptosis.[10] Putterman (1972) further improved the technique by excising the Müller’s muscle alone without damaging the tarsal plate.[11]

Correction of ptosis is essentially surgical with few exceptions.  The techniques most commonly used in adult ptosis are Levator repair (Anterior approach) and Muller’s muscle-conjunctival resection (Posterior approach). Frontalis sling is seldom used in adult patients. However, it is the preferred technique for myogenic and neurogenic ptosis where the risk of exposure keratopathy is high and sling surgery can be easily reversed in such scenarios.

Levator Aponeurosis Advancement procedure

It is the procedure of choice for aponeurotic and involutional ptosis which is caused by dehiscence, disinsertion or thinning of the levator aponeurosis. The procedure can be combined with an upper eyelid blepharoplasty in patients with associated dermatochalasis.

Skin markings

The upper eyelid crease is marked prior to infiltration of local anesthetic in order to maintain symmetry between the two eyes. Skin markings should be done with the patient in sitting posture and eyes in primary gaze. In patients with a preexisting faint eyelid crease, the same crease can be marked. Patients with unilateral ptosis presenting with a raised or absent lid crease, markings are made based on the contralateral normal eyelid crease. However, in patients with bilateral ptosis, the lid crease is marked at 8-10mm along the papillary plane and tapered to 5-6mm medially and laterally.

Anesthesia

Local anesthetic infiltration is done with 2% lidocaine containing 1 to 100000 epinephrine. Epinephrine causes vasoconstriction and thus prevents the spread of the drug and helps in hemostasis. 1 to 1.5ml of local anesthetic is infiltrated along the skin marking. Excessive infiltration is avoided to prevent complete paralysis of the levator which makes it difficult to assess the lid position during surgery. Additional IV sedation with monitored anesthetic care can be given to reduce anxiety but over sedation should be avoided.

Surgical steps

Routine cleaning and draping of the face are done.  It is important to keep both eyes exposed to assess the lid position during surgery.

Lid crease incision is made with a 15 blade. Unipolar cautery or CO2 laser can also be used to make the lid crease incision which helps in hemostasis.

Dissection is then done to open the orbicularis oculi muscle along the entire length of the incision which exposes the orbital septum below. Orbicularis oculi muscle if hypertrophied can be partially excised along the incision.

Dissection is done inferiorly in the sub orbicularis oculi plane to expose the upper part of the tarsal plate. Excessive dissection up to the lid margin is avoided as it causes post-operative lash ptosis.

The orbital septum is now opened. Orbital septum is identified by applying pressure gently over the globe which causes the pre-aponeurotic fat pad to bulge forward. The septum is carefully incised over the prolapsed fat using Westcott scissors and the dissection carried medially and laterally to open the entire septum. Care should be taken to open the septum slightly higher up on the lid to avoid any inadvertent damage to the aponeurosis below.

The preaponeurotic fat is gently separated from the underlying levator by blunt dissection and using cotton tip applicator. A Desmarre’s retractor is used to retract the fat, and all fibrous connections between the septum and levator must be released to avoid post-operative lid retraction.

The disinserted or dehisced aponeurosis is identified as a faint white line at the level where the septum fuses with the aponeurosis. In such cases, the muller’s muscle with the peripheral arterial arcade on its anterior surface can be seen above the superior border of the tarsal plate. In some patients, the aponeurosis may be thinned out or infiltrated with fat.

The levator is now advanced and re-attached to the upper one-third of the tarsus using a double-armed 5-0 vicryl or polyester suture.

A partial thickness suture is taken through the central part of the tarsus 2mm below the superior edge. The eyelid should be everted and checked to ensure that the suture has not passed through the entire thickness of the tarsus. This is important to avoid corneal abrasions. The suture is then passed through the disinserted edge or higher on the aponeurosis in a horizontal mattress fashion and a slip knot tied. The patient is asked to open eyes and lid position assessed both in the lying down and sitting posture. The level of suture placement on the aponeurosis may be increased or decreased to achieve the desired eyelid height and contour. Once the desired lid height is achieved the suture is tied and cut. Similar sutures are then passed medial and lateral to the central suture, lid contour and height assessed and permanent knots placed.

Eyelid crease forming sutures may be placed if required using two or three interrupted sutures using 6-0 ethilon which pass from the lower skin edge, a partial thickness bite is then taken through the levator aponeurosis and the needle is then passed through the upper skin edge and a permanent knot tied.

The wound is closed with interrupted 6-0 plain gut or ethilon sutures. Antibiotic ointment is applied over the wound. A temporary eye patch may be applied.

Post-operatively patient is advised to place ice compresses over the lids for the first 48 hours. Antibiotic ointment is applied over the wound and lubricating eye drops used frequently. Suture removal occurs 7 to 10 days post-operatively.

Muller’s muscle-conjunctival resection (MMCR)

This posterior approach technique is useful for patients presenting with mild ptosis and excellent levator function or ptosis secondary to Horner’s syndrome and anophthalmic socket. It is a modification of the Fasanella – Servat procedure where a bit of tarsus is removed along with conjunctiva and muller’s muscle. Prior to surgery, it is imperative to perform a 2.5% phenylephrine test and confirm elevation of the ptotic lid. If the ptotic lid elevates by 2mm, Dresner recommends 4mm of MMCR for every 1mm of ptosis correction.[12] However, this is variable and individualized based on each surgeon’s technique. Another prerequisite for surgery is to ensure adequacy of healthy conjunctiva in the superior fornix.

Anesthesia

The upper eyelid is everted and 1-2ml of 2% lidocaine containing 1:100000 epinephrine is infiltrated above the superior border of the tarsus to produce ballooning of the conjunctiva. An additional lid crease infiltration and IV sedation under monitored anesthetic care may be given.

Surgical steps

Routine cleaning and draping of the face are performed.  Both eyes are kept exposed to assess the lid position during surgery.

Eyelid traction sutures are taken with 5-0 mersilk sutures. The upper eyelid is everted using Desmarres retractor and held in position by clamping the traction sutures to surgical drapes over the forehead.

The conjunctiva is dried with gauze and markings are made above the superior tarsal border. Another marking is made superior to the first marking at a distance which is equal to half the desired MMCR (For a patient who requires 2mm of ptosis correction an 8mm of MMCR is required. In this case the superior conjunctival marking is made at 4mm from the superior tarsal marking).

Three 6-0 silk sutures are passed through the superior conjunctival markings. The sutures are passes such that they incorporate only the conjunctiva and Muller's muscle. Traction is applied to the sutures which causes separation of the conjunctiva and muller’s from the underlying levator aponeurosis. The Desmarres retractor is removed.

A Putterman mullerectomy clamp is then placed at the base of the tented tissue ensuring that the tarsus is not incorporated in the clamp.

A double-armed 6-0 plain cut or vicryl suture is then passed in a running horizontal mattress fashion below the clamp from one end to the other.

The clamped conjunctiva and Muller’s are then resected using a 15 blade, and the tissues cut using metal on metal contact between the blade and Putterman clamp.

The suture is then passed in the reverse direction from one end of the wound to the other in a running horizontal mattress fashion and a knot tied. Another technique is to pass the suture ends from the conjunctival side through the full thickness of the eyelid and exit on the skin side and secured. In such cases, suture removal occurs after 1 week.

Post-operatively patient is advised to place ice compresses over the lids for the first 48 hours. The patient should apply antibiotic ointment at bedtime for a week, and lubricating eye drops used frequently.

Frontalis sling surgery

Frontalis sling is commonly performed in patients with severe ptosis and poor levator action (less than 4mm). This procedure is often used in adults with myasthenia gravis, chronic progressive external ophthalmoplegia, IIIrd nerve palsies and other conditions that lead to a very weak levator function. It is the procedure of choice in severe congenital ptosis with poor levator action, but other indications for sling surgery include myogenic ptosis, neurogenic ptosis, blepharophimosis syndrome, and Marcus Gunn jaw-winking syndrome.

The frontalis muscle contributes about 2 to 3 mm of eyelid elevation. This action is utilized in frontalis sling surgery where the eyelid is suspended to the frontalis muscle to achieve eyelid elevation. Various materials are used for suspension which may be autogenous, allogenic or synthetic.

Autogenous materials include fascia lata, palmaris longus tendon, and temporalis fascia. Allogenic material consists of banked fascia lata.  Synthetic materials include polypropylene (prolene), supramid nylon suture, mersilene mesh, and silicone.[13]

Among these, the most widely used are silicone rod and fascia lata with the latter being the gold standard material of choice.

There are two techniques of frontalis sling: Crawford technique and Fox pentagon. The Fox pentagon with fewer stab incisions is faster and easier to perform and is the technique most commonly followed.

Skin markings (Fox pentagon method)

It consists of 5 small incisions. Two eyelid markings are made 2mm from the lid margin at the medial and lateral limbus. These markings can be adjusted to get a good contour which can be determined using a forceps to raise the lids. Two eyebrow markings are made just above the eyebrows corresponding to the medial and lateral canthus. A central forehead incision is made in the pupillary plane slightly higher than the eyebrow markings. 

Anesthesia

General anesthesia is the preferred choice for children; however, local anesthesia with intravenous sedation is better for adults. Local anesthetic infiltration is with 2% lidocaine containing 1 to 100000 epinephrine. The local anesthetic infiltrates along the skin marking, and pressure applied.

Surgical steps

Routine cleaning and draping of the face are p.  Both eyes remain exposed to assess the lid position during surgery. The forehead is also kept exposed to pass the sling.

Stab incisions are made through the skin markings. The central forehead incision is widened to 3 to 5mm.

The sling loaded on a needle is passed from the central forehead incision and brought out through the medial eyebrow incision engaging the frontalis muscle. It is then passed from the medial eyebrow incision to the medial eyelid incision passing deep to the orbicularis oculi but anterior to the orbital septum and tarsal plate.

Next, it is passed from the medial to the lateral eyelid incision. Here the sling lies superficial to the tarsus. Care is necessary to avoid globe injury. This can be achieved by using a lid guard.

The sling is now passed in the reverse direction from the lateral eyelid incision to the lateral eyebrow and subsequently out through the central forehead incision. The lid height is now adjusted on the table and when the desired contour is achieved the sling is secured with a silicone sleeve and the excess sling material cut. The sling with the sleeve is then buried in a pocket created. The incisions are then sutured with 6-0 plain gut.

Frost suture may be taken through the lower eyelid to protect the cornea in the immediate post-operative period. 

Post-operatively patient is advised to place ice compresses over the lids for the first 48 hours. The patient should apply antibiotic ointment at bedtime for a week, and lubricating eye drops used frequently. Frost suture removal is performed after 48 hours.

Complications

Undercorrection

This phenomenon may occur with any technique. In the immediate post-operative period, the lid appears undercorrected due to the lid edema. Patients may be reassured. However, if the under-correction persists then revision surgery may be required. The wound can be reopened and aponeurosis re-advanced.

Overcorrection

Overcorrection is more often encountered following advancement for aponeurotic/involutional ptosis. Mild overcorrection in the immediate postoperative period may be tackled with eyelid traction. The patient may be asked to look downward and pull on the eyelashes with the thumb and forefinger; this may be done for a few minutes 3 to 4 times a day. Severe overcorrection will require immediate revision. The wound can be reopened and the sutures cut. The levator is then placed at a more recessed position or secured to the tarsal plate using hang back sutures.

Lagophthalmos and exposure keratopathy

All patients are counseled pre-operatively about post-operative lagophthalmos and decreased blink rate. Management of lagophthalmos in the immediate post-operative period is with copious lubricants. A temporary frost suture may be applied. In cases where severe exposure keratopathy develops a revision surgery is done to lower the lid height.

Eyelid contour defects

Contour defects occur due to improper placement of sutures on the tarsus. Patients presenting with small contour defects usually settle down with time. Lid massage and eyelid traction exercises are advised. Persistent or severe contour abnormalities require revision surgery and proper placement of sutures on the tarsus.

Conjunctival prolapse

Extensive dissection between the conjunctiva and levator can disrupt the suspensory ligaments of the superior fornix and produce conjunctival prolapse. Mild prolapse can be treated conservatively with lubricants. Severe prolapse requires repositioning of the conjunctiva with pang sutures; suture is passed through the prolapsed conjunctiva and secured at the skin crease.

Eyelash ptosis

Excessive dissection of the orbicularis from the tarsus results in lash ptosis, which can be corrected by anterior lamella repositioning sutures.

Suture granuloma

Small granulomas can form at the suture site. They can be excised with Wescott scissors and the base cauterized. The suture causing the granuloma also requires removal.

Clinical Significance

Ptosis correction helps restore the field of vision and also improves the aesthetic appearance; it reverses the feeling of heaviness in the eye. Most patients feel and look younger thus improving their quality of life.

Enhancing Healthcare Team Outcomes

Adult ptosis is a common condition encountered in ophthalmic clinics by the ophthalmic nurse, optician, and the ophthalmologist. THese interprofessional entities need to collaborate in a team approach to patient care in ptosis cases. Oculoplastic and plastic surgeons perform ptosis correction. Practicing surgeons should be aware of the anatomy, etiology, examination and surgical techniques for ptosis correction. Surgeons should be well aware of what surgery to perform when and also when not to operate.