Ptosis surgery

1. Jagdish Dukre

2. TREATMENT
Non-surgical – Rehabilitative crutch glasses
Surgical - Definitive Treatment
Decision making
When to operate Which procedure
concern is cosmetic any age
concern is amblyopia early surgery
squint has to be operated first
blepharophimosis, telecanthus, epicanthus operated first
Depends on levator function
+ associated anomaly

3. Levator function
>10mm <10mm
Degree of ptosis Levator function
<2mm >2mm >4mm <4mm
Fasanella servat Aponeurosis surgery Levator resection brow
(tarso-conjunctivo / Levator plication suspension
mullerectomy)

4. MODIFIED FASANELLA – SERVAT
- Involves tarso-conjunctivo-mullerectomy
- Best results upto 2mm congenital ptosis with minimum
10mm levator action
- 2mm tarsectomy performed for every 1mm ptosis
- Used for mild neurogenic or myogenic ptosis & residual
ptosis following levator resection procedure
- ANESTHESIA – Local or General

5. SURGICAL STEPS
Upper eyelid everted
Three 4-0 traction sutures placed at upper border
of tarsal plate

6. Required amount of tarsal resection marked over
everted tarsus staying parallel to eyelid margin.
Tarsus marked along line of excision with
monopolar cautery.
Full thickness excision performed along entire
extend.

7. Skin suture placed with 6-0 catgut at medial end
of tarsal excision & needle brought out on
conjunctival side to close tarsal wound.
Tarsal wound closed with continuous 6-0 catgut
suture.
Suture end finally exteriorized on to eyelid skin at
lateral end for final knot.

8. LEVATOR RESECTION
TRANSCUTANEOUS APPROACH (Everbusch operation)
Upper eyelid crease incision marked maintaining
symmetry with contra lateral eye.
Skin incision placed.
After central suture placement

9. Orbicularis separated to expose orbital septum.
Superior tarsal plate.

10. Orbital septum incised to expose pre-aponeurotic fat
pad & levator aponeurosis.
Whitnall’s ligament visualized on retracting
overlying pad of fat as whitish fascial condensation
running across junction of muscular & aponeurotic
part of levator.
Conjunctiva lifted away from levator aponeurosis by
subconjunctival injection of xylocaine.

11. 4-0 silk traction sutures placed through levator
aponeurosis at its insertion.
Levator disinserted & separated from underlying
muller’s–conjunctiva by blunt dissection / hydro
dissection.

12. Medial & Lateral horn’s cut if necessary.
Three cardinal sutures passed from tarsus through
levator muscle at desired height.
Sutures are tightened with temporary knot’s to
achieve
predetermined lid height & natural contour.
Placement of upper eyelid sutures during surgery
based on levator action

13. Beard’s guidelines for levator
resection
Degree of ptosis LFT Approximate resection
Mild Good ( 8-12mm) Small (10-13mm)
Fair (5-7mm) Moderate (14-17mm)
Moderate Good ( 8-12mm) Moderate (14-17mm)
Fair (5-7mm) Large (18-22mm)
Poor ( <4mm) Maximum (23-27mm)
Severe Fair (5-7mm) Maximum (23-27mm)
Poor (<4mm) Supermaximal (27 or more)
/ Frontalis sling

14. Redundant stump of aponeurosis excised
Lid crease formed with three interrupted 6-0 vicryl
sutures passed through orbicularis muscle including
levator stump.
Skin closed with 6-0 prolene continuous sutured.

15. TARSOFRONTALIS SLING
Ideal procedure for bilateral moderate to severe ptosis with poor
levator action.
Unilaterally in rare situations – Following levator excision for
marcus– Gunn phenomenon
- Severe unilateral ptosis with poor
levator action.
Performed with-
1. Non absorbable synthetic materials – 3-0 ethibond suture,
3-0 prolene suture, silicon material.
2. Autogenous fascia lata/Temporalis fascia - Best sling material.
Performed under local / general anaesthesia

16. Eyelid incisions marked over upper eye lid 1cm apart,
3-4mm from lash line.
Central brow incision 10-12mm above superior
border of eyebrow.
Lateral & medial brow incision marked above
eyebrow in line with lateral & medial canthus.
MARKING INCISIONS
Stab incisions made with Bard-parkar knife.
Lid incisions placed in skin & orbicularis.
Brow incision upto frontalis muscle.
Needle attach to silicon rod passed in
suborbicularis plane from central brow incision to
lateral brow incison.

17. Needle then passed towards lateral eyelid stab
incision.
Eyeball protected by lid guard.
Passed through medial eyelid incision.
Medial brow incision.
Finally out through central brow incision.

18. Silicone sleeve fed over to ends of silicone rod
that are brought out through central brow
incision.
Eyelid height adjusted to desired level by
applying traction over each end of silicone rod.
Silicone sleeve transfixed to subcutaneous
tissue within brow incision with 6-0 prolene
sutures.

19. Wound closed with interrupted 6-0 prolene
sutures.
Frost suture placed before patching the eye.

20. COMPLICATIONS OF PTOSIS SURGERY
1. Under correction – Most frequent after congenital ptosis surgery
• May improve as edema subsides
• Persistent under correction – requires repeat surgery after 4-6
months.
• Obviously under corrected eyelid - corrected within a week or
two immediately after surgery .
2. Over correction – Following surgery for acquired ptosis
Rare in congenital ptosis
Treatment - Various methods
Downward traction over eyelid with forceps (requires L.A)
Surgical correction

21. 3. Localized lid contour abnormalities
Treatment – Loosening cardinal suture for localized peaking
Further small levator resection for localized flattening
4. Lid Crease Abnormalities –
Absence of crease
improper position
overhanging skin
Treatment – may require re-formation of eyelid crease at desired level
5. Conjunctival Prolapse –
occur if forniceal attachment of levator disturbed during post dissection
Improves without treatment
May require fornix formation suture
Excision of excess conjunctiva in some cases

22. 6. Lagophthalmos
- d/t - improper dissection of LPS aponeurosis from surrounding
structures.
- Overresection of LPS.
- Tt- Massage
Tarsotomy
Levator recession
7. Exposure Keratitis
- d/t overcorrection, lagophthalmos, decreased tear production or poor
Bell’s phenomenon.
- Treatment – Artificial tear substitute
Punctal occlusion
Tarsorrhaphy
8. Recurrence following surgery