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ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 2  |  Page : 636-640

Maximal levator resection in congenital blepharoptosis


Department of Ophthalmology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission14-Dec-2019
Date of Decision04-Jan-2020
Date of Acceptance11-Jan-2020
Date of Web Publication27-Jun-2020

Correspondence Address:
Ola E Abdou
Shebin El-Kom, Menoufia 12345
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_383_19

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  Abstract 


Objective
The aim was to evaluate the surgical effect of maximal levator muscle resection technique for moderate to severe simple congenital blepharoptosis with poor levator function.
Background
Surgical treatments for the correction of congenital ptosis with poor levator function including frontalis suspension or maximal levator resection remain controversial. However, the levator resection approach seems to be the most physiological. Maximal levator resection, assuming that it is employed appropriately, is highly effective in cases of moderate to severe congenital ptosis with poor levator function. This surgery advances and plicates the levator muscle, thus increasing its effect.
Patients and methods
This prospective study included 29 eyelids of 20 patients who underwent maximal levator resection procedure, and their ages ranged from 3 to 8 years. Patients who presented with ptosis were examined and enrolled from January 2018 to January 2019, from the Outpatient Ophthalmic Clinic of Menoufia University Hospital. Follow-up was done at first week, first month, and sixth month postoperatively to evaluate the functional, cosmetic results, and complications.
Results
There is a statistically significant increase of mean postoperative marginal reflex distance-1 (MRD-1) at first week, first month, and sixth month in comparison with preoperative MRD-1 (P < 0.05). Successful outcome of the maximal levator resection procedure that was evaluated by postoperative MRD-1 was met by 79.31% (23/29) in the first week, 82.76% (24/29) in the first month, and 86.21% (25/29) in the sixth month. Satisfactory eyelid contour was met by 28 of 29 eyelids. The most common complications at 6 months were undercorrection in 10.3% (3/29) and overcorrection in 3.4% (1/29).
Conclusion
Maximal levator resection procedure is very effective in the treatment of simple congenital blepharoptosis with poor levator function.

Keywords: blepharoptosis, congenital, maximal levator resection


How to cite this article:
Mandour SS, Rajab GZ, Abdou OE. Maximal levator resection in congenital blepharoptosis. Menoufia Med J 2020;33:636-40

How to cite this URL:
Mandour SS, Rajab GZ, Abdou OE. Maximal levator resection in congenital blepharoptosis. Menoufia Med J [serial online] 2020 [cited 2020 Dec 2];33:636-40. Available from: http://www.mmj.eg.net/text.asp?2020/33/2/636/287793




  Introduction Top


Blepharoptosis is defined clinically as an abnormal low-lying upper eyelid margin more than 2 mm below the superior corneal limbus in the primary gaze[1]. Blepharoptosis can be classified into several ways. It may be classified as congenital or acquired, unilateral or bilateral, and as aponeurotic, myogenic, neurogenic, or mechanical. It can be subdivided further according to the amount of levator function into poor (0–5), fair (6–11), or good (12 or more) millimeter (mm)[2]. It may be classified also according to the degree of ptosis into mild [marginal reflex distance-1 (MRD-1)=2 mm], moderate (MRD-1=3 mm), and severe (MRD-1=4 mm or more). Surgical options for each of these groups are based on levator function as well as the degree of and the cause of ptosis[3].

There are several methods for surgical correction of ptosis, including levator muscle resection, frontalis sling, the Fasanella–Servat procedure, and Muller muscle–conjunctival resection[4]. Levator resection, assuming that it is employed appropriately, is highly effective in cases of simple congenital ptosis. This surgery advances and plicates the levator muscle, thus increasing its effect[5]. Maximal levator resection, unlike frontalis suspension, does not introduce any exogenous suspension material into the upper eyelid, thereby avoiding the risk of infection, extravasation, and extrusion of the suspension material. It does not require autogenous fascia lata, thereby avoiding the creation of a scar and multiple incision sites, as well as reducing operating time, which is a major concern with young children[6],[7]. In addition, this procedure creates an upper eyelid crease that produces a more normal-appearing upper eyelid compared with that of the frontalis suspension procedure. Furthermore, levator resection does not require surgical manipulation of the contralateral normal eyelid[8].

The aim of the present work was to evaluate maximal levator resection technique in the management of moderate and severe ptosis with poor levator function, regarding satisfactory functional and cosmetic results as well as complications.


  Patients and Methods Top


This was a prospective nonrandomized interventional study that included a total of 29 eyelids of 20 patients eligible for the study who underwent maximal levator resection procedure, and their ages ranged from 3 to 8 years.

Patients presented with ptosis were examined and enrolled from January 2018 to January 2019 from the Outpatient Ophthalmic Clinic of Menoufia University Hospital. Written informed consent was obtained from their guardians before surgery, which was approved by the local Ethics Committee and in accordance with declaration of Helsinki.

Patients included in this study had simple congenital blepharoptosis with poor (0–5 mm) levator function, which was moderate (MRD-1=3 mm) and severe (MRD-1=4 mm or more) ptosis. Therefore, patients were excluded from this study who had mild ptosis, good and fair levator function, myasthenia gravis, Marcus Gunn jaw-winking syndrome, dysthyroid ophthalmopathy, underwent previous blepharoptosis surgery, and traumatic ptosis. Moreover, patients who had poor Bell's phenomenon and severe dry eye were excluded.

A complete ophthalmic examination including visual acuity using Snellen chart, extraocular muscles motility by utilizing the H motility pattern, and refraction, was done. Detailed slit lamp examination including anterior segment examination, intraocular pressure measurement with a tonometer and detailed fundus examination was also done. Corneal protective mechanisms including Bell's phenomenon, orbicularis muscle tone, and corneal sensation by the use of a cotton-tipped applicator were specifically checked. Upper lid crease position, levator muscle function (LF), and MRD measurements were recorded for evaluation of ptosis, and systemic examination was therefore done for all selected cases.

Surgical procedure

All surgeries were done under general anesthesia by the same surgeon (Mandour S.S.).

Under aseptic precautions, the eyelid crease line was marked using a marker. If the eyelid crease line was not present, the future eyelid crease was created using the caliber and a marker at a distance of 5–7 mm from the eyelid margin or matching the contralateral eyelid crease. This distance varied with each case and was determined intraoperatively. The intended skin crease was marked before local infiltration of 1–2 ml of 2% lignocaine with 1:200 000 adrenaline. Deeper injection was avoided to prevent a hematoma, and then massage was done for 5–10 min.

A 4/0 silk traction suture (Richmond Medical, China) was placed through the gray line of the upper eyelid at the desired location of the peak of the eyelid and fixated to the face drapes using a small hemostat. Skin crease was incised with Bard Parker blade No 15 (Myco Medical, China). Two toothed forceps (Mortech Mfg, India) hold the two edges of skin incision at the center upward and a central cut in orbicularis oculi was done with Wescott scissors (Liaoning, China). The rest of orbicularis was then opened horizontally with Wescott scissors.

The skin-muscle flap was then dissected superiorly exposing the orbital septum and underlying preaponeurotic fat pad. The septum was opened horizontally throughout the entire length of the incision and the preaponeurotic fat pad was exposed, which was retracted superiorly to display the levator aponeurosis, Whitnall's ligament, and levator muscle. Caliber was used to measure the amount of aponeurosis to be resected, which varies from 25 to 30 mm. The edge of levator aponeurosis was identified and dissected off the tarsus throughout the entire length of the incision.

The most important step was the sufficient mobilization of the levator muscle, whereas the lateral and medial horns are completely dissected under preservation of the transverse ligament. The levator aponeurosis was dissected from underlying Müller's muscle. The horns of the levator were cut.

The superior 3–4 mm of tarsus was exposed by dissecting away the overlying pretarsal orbicularis. Three double-armed mattress sutures of 5-0 vicryl (Richmond Medical) were passed in a lamellar fashion through the tarsus at the junction of the upper 1/3 with the lower 2/3 of the tarsus in a transverse orientation taking care to protect the underlying globe. The initial suture was placed just above the silk traction suture to ensure the maximum peak was at this position. Both arms of the 5/0 vicryl suture were passed through the levator aponeurosis at the desired distance from the tarsus and tied in a loop fashion. The two additional 5/0 vicryl sutures were passed through the tarsus and through the aponeurosis. The excess levator aponeurosis was then excised. The skin incision was closed incorporating the levator aponeurosis to reform the skin crease. Lower eyelid Frost suture was applied followed by compressive dressing for 48 h. Ice packs were applied intermittently for 24 h.

Postoperatively, all patients received prophylactic combined steroid and antibiotic eye drops four times daily for one week and combined steroid and antibiotic eye ointment once daily at night for one month.

Systemic antibiotics, anti-inflammatory drugs for 1 week, and analgesics were received when needed. Regarding follow-up, the patients were examined up at 1 week, 1 month, 3 months, and 6 months postoperatively for MRD-1 measurements and incidence of complications. Skin sutures were removed at the 1-week follow-up.

Statistical analysis

All data were collected, tabulated, and statistically analyzed using Statistical Package for the Scientific Studies (SPSS) version 22.0 (SPSS Inc., Chicago, Illinois, USA). Data were statistically described in terms of mean, SD and range, or percentages when appropriate. Preoperative and postoperative values were compared using analysis of variance test and χ2-test. P values less than 0.05 were considered statistically significant.


  Results Top


The current study included 29 eyelids of 20 children with simple congenital ptosis who underwent maximal levator resection technique. There were 12 male and 8 female. The age of the patients in this study ranged from 3 to 8 years, with a mean of 5 years old. Nine of cases were bilateral and 11 unilateral. Right side comprised 17 eyelids and left 12 eyelids. There were nine cases of moderate ptosis and 20 cases of severe ptosis ([Table 1] and [Table 2]).
Table 1: Age distribution in the study group (n=20 cases)

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Table 2: Laterality and grade distribution of ptosis in the study group

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There is a statistically significant increase of mean postoperative MRD-1 at first week, first month, and sixth months, in comparison with preoperative MRD-1 (P < 0.05) [Table 3].
Table 3: Comparison between preoperative and postoperative marginal reflex distance-1 in the study group by analysis of variance test and pairwise comparisons (n=29 eyes)

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Regarding mean postoperative MRD-1 at 1 month in successful cases in comparison with failed cases (P < 0.05), there is a statistically significant increase between them. Moreover, there is a statistically significant increase of mean postoperative MRD-1 at 6 months in successful cases in comparison with failed cases (P < 0.05) [Table 4]. No statistically significant difference of percentage of successful cases according to ptosis grade (P > 0.05) [Table 5].
Table 4: Comparison of pre and postoperative ocular measurements according to success rate at 6 months in the study group by analysis of variance test (n=29 eyes)

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Table 5: Relation between success rate and ptosis grade by χ2-test in the study group (n=29 eyes)

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There is a statistically significant positive correlation between muscle excision and postoperative MRD-1 sixth month (P < 0.05) [Table 6].
Table 6: Pearson correlation between muscle excision and improvement in ptosis degree

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Regarding surgical outcome of levator resection technique, postoperative success rate that evaluated by postoperative MRD-1 is 79.31% (23/29) in the first week, 82.76% (24/29) in the first month, and 86.21% (25/29) in the sixth month. Satisfactory eyelid contour has been achieved in 28 of 29 eyelids. [Figure 1] shows a case with preoperative and postoperative successful levator resection.
Figure 1: Case no 2 with preoperative and postoperative right levator resection.

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Regarding the complications in this study, three patients were undercorrected and one patient was overcorrected. Exposure keratopathy associated with lagophthalmos was recorded in one patient, who was managed successfully with lubricants. Lateral sagging was also reported in one case until the end of follow-up. High lid crease was reported in one patient [Figure 2].
Figure 2: Case no 15 with left high lid crease level.

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  Discussion Top


Several different types of surgical procedure are used for correction of blepharoptosis. The surgical procedure chosen generally depends on the amount of levator function. When levator function is poor or absent, frontalis suspension remains the preferred surgical procedure for correction of congenital blepharoptosis[9]. However, Cruz et al.[10] reported that anterior levator resection can be used in all types of congenital ptosis and even in cases of poor levator function. Levator resection technique is more anatomic and physiologic than frontalis suspension, which achieves satisfactory eyelid height, and with no brow scar[11].

In this study, cases of moderate and severe congenital blepharoptosis with poor levator function were recruited, evaluated, and treated surgically with maximal levator resection technique. The choice of the amount of resection is considered individually, depending on the severity of upper eyelid ptosis and the amount of levator function. The results of surgical treatment were evaluated and documented over a follow-up period of 6 months.

In this work, preoperative levator function ranged from 1 to 5 mm with an average 3.06 ± 1.3 mm. This was in agreement with the study of Al-Mujaini and Wali[12], and Attarzadeh et al.[13], which recorded that preoperative levator function ranged from 2 to 4, with an average 3.4 ± 0.9 mm. The importance of the levator function in determining the success rate agreed with the findings of Jordan and Anderson, who demonstrated more late undercorrections in patients with lesser degrees of levator function. However, this conclusion is not universal. Blomgren using levator resection and Berlin using aponeurosis advancement found that the degree of preoperative ptosis was more relevant to the outcome than levator function[11].

Regarding mean preoperative MRD-1 in this study, it was −0.65 ± 1.05 mm, whereas mean postoperative MRD-1 at the end of the follow-up was 3.55 ± 1.47 mm. Attarzadeh et al.[13] recorded in their study that the mean MRD-1 was increased from 0 ± 1 preoperatively to 4.1 ± 0.4 postoperatively. In another study that included 29 eyelids of 23 patients who underwent maximal levator resection surgery, preoperative mean MRD-1 was −0.14 ± 1.6 mm, whereas postoperative mean MRD-1 was 2.6 ± 1.2 mm[14].

With this approach, we obtained successful results regarding improvement on MRD-1 in 86.21% (25/29) at the end of the follow-up. Satisfactory eyelid contour has been achieved in 28 of 29 eyelids. Press and Hübner[15] reported that 82% (36/44) of patients achieved a satisfactory eyelid elevation for congenital ptosis with poor levator function. In another study, 84 children underwent levator resection for unilateral severe congenital blepharoptosis, and 84.5% had surgical success at the end of the follow-up[11]. This difference in results may be owing to variance in number of cases and period of studies.

In this study, we had poor results in four patient. Three cases of them were undercorrected (10.3%) and one was overcorrected (3.4%). This is comparable to the work of Cates and Tyers[16], which recorded an overcorrection rate of 7% and undercorrection rate of 19% in their series, which included 100 consecutive cases (108 lids) of anterior levator resection undertaken for congenital levator dystrophy, reviewed retrospectively.

Although maximal levator resection can achieve successful surgical results in patients with poor levator function, there are some potential complications, such as recurrence, exposure keratopathy and lagophthalmos, lid crease asymmetry, conjunctival prolapse, lateral sagging, and eversion of the upper eyelid[17]. Regarding complications in our work, one patient developed exposure keratopathy associated with lagophthalmos (3.4%), which was treated successfully with lubricants and recovered in the first 20 days postoperatively.

Exposure keratopathy and lagophthalmos were reported in three (2.7%) patients in the study by Cates and Tyers[16]. Lee et al.[18] also reported that 27 (11.1%) patients had developed exposure keratopathy in their study, which included 243 eyelids that underwent maximal levator resection.

Lateral sagging was reported in 3.4% of cases. This complication was also reported in the study by Wu et al.[11] in 2.4% of cases. Lid crease asymmetry, which was represented in our study as high lid crease, was reported only in one (3.4%) patient until the end of follow-up. This complication was also reported in the study by Lee et al.[18] in 8.2% of cases and in the study by Cates and Tyers[16] in 2.8% of cases.


  Conclusion Top


Maximal levator resection surgery is effective cosmetically and functionally for the repair of moderate and severe simple congenital blepharoptosis with poor levator function, being a simple procedure, less time consuming, does not require extensive dissection, as well as respects the normal physiology of levator muscle and preserving its innervation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Innocenti A, Mori F, Melita D, Dreassi E, Ciancio F, Innocenti M. Evaluation of long-term outcomes of correction of severe blepharoptosis with advancement of external levator muscle complex: descriptive statistical analysis of the results. In Vivo 2017; 31 :111–116.  Back to cited text no. 1
    
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Bernardini FP, Cetinkaya A, Zambelli A. Treatment of unilateral congenital ptosis: putting the debate to rest. Curr Opin Ophthalmol 2013; 24 :484–487.  Back to cited text no. 2
    
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Nemet AY. Accuracy of marginal reflex distance measurements in eyelid surgery. J Craniofac Surg 2015; 26 :569–571.  Back to cited text no. 3
    
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Yadegari S. Approach to a patient with blepharoptosis. Neurol Sci 2016; 37 :1589–1596.  Back to cited text no. 4
    
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Putterman AM. Mullerectomy procedure with skin crease preservation. Ophthalmic Plast Reconstr Surg 2016; 32 :237–237.  Back to cited text no. 5
    
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Hou D, Li G, Fang L, Li B. Frontalis muscle flap suspension for the correction of congenital blepharoptosis in early age children. PLoS One 2013; 8 :185–205.  Back to cited text no. 6
    
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SooHoo JR, Davies BW, Allard FD, Durairaj VD. Congenital ptosis. Survey Ophthalmol 2014; 59 :483–492.  Back to cited text no. 7
    
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Göncü T, Çakmak S, Akal A, Karaismailoglu E. Improvement in levator function after anterior levator resection for the treatment of congenital ptosis. Ophthalmic Plast Reconstr Surg 2015; 31 :197–201.  Back to cited text no. 8
    
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Skaat A, Fabian ID, Spierer A, Rosen N, Rosner M, Simon GJ. Congenital ptosis repair – surgical, cosmetic, and functional outcome: a report of 162 cases. Canadian J Ophthalmol 2013; 48 :93–98.  Back to cited text no. 9
    
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Cruz AA, Akaishi PM, Mendonça AK, Bernadini F, Devoto M, Garcia DM. Supramaximal levator resection for unilateral congenital ptosis: cosmetic and functional results. Ophthalmic Plast Reconstr Surg 2014; 30 :366–371.  Back to cited text no. 10
    
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Wu SY, Ma L, Huang HH, Tsai YJ. Analysis of visual outcomes and complications following levator resection for unilateral congenital blepharoptosis without strabismus. Biomed J 2013; 36 :179–187.  Back to cited text no. 11
    
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Al-Mujaini A, Wali UK. Total levator aponeurosis resection for primary congenital ptosis with very poor levator function. Oman J Ophthalmol 2010; 3 :122.  Back to cited text no. 12
    
13.
Attarzadeh A, Nowroozzadeh MH, Sharifi M, Zamani E. Combined maximum levator resection and septal sling in correction of severe blepharoptosis with poor levator function. Iran J Ophthalmol 2008; 20 :34–39.  Back to cited text no. 13
    
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Mete A, Cagatay HH, Pamukcu C, Kimyon S, Saygılı O, Güngör K. Maximal levator muscle resection for primary congenital blepharoptosis with poor levator function. Seminars Ophthalmol 2017; 32 :270–275.  Back to cited text no. 14
    
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Press UP, Hübner H. Maximal levator resection in the treatment of unilateral congenital ptosis with poor levator function. Orbit 2001; 20 :125–129.  Back to cited text no. 15
    
16.
Cates CA, Tyers AG. Outcomes of anterior levator resection in congenital blepharoptosis. Royal Coll Ophthalmol 2001; 15 :770–773.  Back to cited text no. 16
    
17.
Cagatay HH, Ekinci M, Apil A, Arslan B, Pamukcu C, Oba ME, et al. The use of polypropylene suture as a frontalis suspension material in all age groups of ptosis patients. J Investig Surg 2014; 27 :240–244.  Back to cited text no. 17
    
18.
Lee JH, Aryasit O, Kim YD, Woo KI, Lee L, Johnson ON. Maximal levator resection in unilateral congenital ptosis with poor levator function. Br J Ophthalmol 2017; 101 :740–746.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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