Ptosis, also known as blepharoptosis, refers to drooping of upper eyelid to a level lower than normal position. Normally the upper lid covers about one-sixth of the cornea, i.e. about 2mm.

Ptosis may either be congenital or acquired.

Crowell Beard classified ptosis as follows4:

·         Congenital ptosis: It is associated with superior rectus weakness / blepharophimosis / Synkinetic ptosis (Marcus jaw winking ptosis)/ Third nervepalsy

·         Acquired ptosis: Neurogenic / Myogenic / Traumatic / Mechanical

The majority of cases of blepharoptosis are congenital, with the reported frequency varying between 62% to 90%1, 2, 3. Congenital ptosis is often due to the poor development of the levator muscle or its replacement by fibrosis, fat, or areolar tissue. Aponeurotic ptosis, also known as involutional or senile ptosis, is a form of acquired ptosis which occurs as a result of levator aponeurosis dehiscence or disinsertion. Surgery in aponeurotic ptosis is indicated in cases of visual axis obscuration and when better cosmesis isrequired.

Evaluation of ptosis includes assessment of visual acuity, strabismus, levator action, Bell’s phenomenon and other abnormalities like superior rectus weakness, blepharophimosis syndrome, synkinetic movements, anisometropia and amblyopia.

Management of ptosis depends on multiple factors like type, severity, levator function, Bell’s phenomenon, co-existence of superior rectus weakness, presence of synkinetic movements and blepharophimosis. Options include Fasanella-Servat procedure, levator resection and advancement, Muller’s muscle-conjunctival resection and traditional frontalis suspension procedures. In general, a patient with severe ptosis and poor levator function is a good candidate for frontalis sling while a person with minimum ptosis with good levator function is suitable for Fasanella-Servat procedure. Moderate-to-severe ptosis is usually treated via an anterior eyelid approach utilising plication, advancement, or resection of LPS5-6. Success rates of levator resection have been variably quoted from 70% to 90%. Rates of cosmetically unsatisfactory eyelid crease and contour abnormalities along with higher revision rates of up to 11% to 30% have been with levator resection5-7. Muller’s Muscle-Conjunctival Repair (MMCR) is another surgery for correction of mild-moderate ptosis but has not been widely used for severe ptosis. However,  some recent data suggest that MMCR may be helpful in a wider array of ptosis8-10.

MATERIALS AND METHODS

 

STUDY DESIGN: Prospective Interventional Study

 

PLACE OF STUDY: Guru Nanak Eye Centre (OPD and Oculoplasty clinic)

 

STUDY DURATION: 12 months

 

SAMPLE SIZE:

     As per the formula:

According Oh et al¹¹ 2018, significant ptosis correction was seen in 96% cases, however standard deviation is not mentioned in the article. Thus using the Margin reflex distance₁ (MRD₁),

Pre-operative mean = 0.3mm, post-operative mean = 3.5mm and thus, the mean difference in MRD₁ is 3.22mm. As the difference is large, we have assumed the effect size to be larger. Therefore we have used the effect size = 0.7 (large).

Level of significance, α = 5%

Power (1-ß) = 80%

The formula used to calculate sample size was:

Where Zα = 1.960 for α = 5%, Zβ = 0.842 and effect size = 0.7

So, n = 17 subjects

 

STUDY POPULATION: Study will comprise of 17 patients meeting the inclusion and exclusion  criteria.

INCLUSION CRITERIA: All patients with -

1.             Involutional ptosis

2.             Congenital ptosis of age ≥5 years

3.             Moderate (amount of ptosis 3mm)  or severe (amount of ptosis ≥ 4mm) ptosis

4.             LPS action more than or equal to 5mm

EXCLUSION CRITERIA:

1.      Marcus gunn jaw winking syndrome

2.      Myasthenic ptosis

3.      Horner’s syndrome

4.      Third nerve palsy

5.      Post-traumatic ptosis

 

 

PRE-TREATMENT EVALUATION

 

HISTORY:

A detailed history regarding onset and progression of the disease and evaluation of possible causative factor like trauma or surgery will be taken. Also history of diplopia, spectacle use, occlusion therapy, redness or diurnal variation will be elicited.

OPHTHALMOLOGICAL EXAMINATION:

1.      Unaided/aided and best corrected visual acuity

2.      Retinoscopy under appropriate cycloplegic agent

3.      Assessment of ocular alignment and motility

4.      Assessment of ptosis

·      Type of ptosis

·       Degree of ptosis (difference in MRD₁ of normal and Ptotic eye)

·      Margin crease height (distance from upper eyelid crease to the eyelid margin)

·      HPA (distance form medial canthus to lateral canthus)

·      VPA (widest point between the lower eyelid and upper eyelid)

·      MRD₁ (distance from the upper eyelid margin to the corneal light reflex in primary position)

·      MRD₂  (distance from the lower eyelid margin to the corneal light reflex in primary position)

·      LPS action (measuring from downgaze to upgaze with frontalis muscle action negated)

·      Bell’s phenomenon

5.      Schirmer’s test

6.      10% Phenylephrine response

7.      Clinical photographs

BLOOD INVESTIGATIONS:

·         Bleeding time

·         Clotting time

·         Haemoglobin

 

SURGICAL TECHNIQUE:

Surgery will be performed under either local anesthesia (2% lignocaine with 1:80,000 adrenaline) or general anesthesia.

CLOSED POSTERIOR LEVATOR ADVANCEMENT:

·         The eyes cleaned and draped after taking all aseptic precautions.

·         Injection 2% lignocaine with 1:80,000 adrenaline will be administered in the tissue plane between Muller’s muscle and conjunctiva.

·         The lid will be marked for the lid crease and exit position of suture.

·         The lid will be double everted over Desmarres retractor. Three points will be marked on the fornceal side of conjunctiva, first in the  center of the tarsus, second point 5mm lateral and the third point 5mm medial to central point.

·         On these marking, stay sutures will be placed through conjunctival and Muller’s muscle.

·         A ptosis clamp will be placed followed by continuous key pattern suturing.

·         If the ptosis is severe with good phenylepherine response, 10mm of Muller’s muscle will be resected. Additional resection of tarsus will be used if suboptimal phenylepherine response is observed. Excision of tarsus will be performed in 1:1 ratio of further elevation (mm) desired.

·         Blade will be used to resect the tissue below the clamp and above the running suture.

·         Pressure will be applied for few minutes to control the bleeding.

·         Revision surgery will be performed if MRD₁ is not within 1mm of the desired height (symmetry within 1mm of fellow eye). 

 

POST-OPERATIVE TREATMENT:

·         Tablet Ciprofloxacin (500 mg 12 hourly) and Tablet Ibuprofen (400 mg 8 hourly) for five days

·         Topical Tobramycin 0.3% (in children) or Ofloxacin 0.3% (in adults) four times a day for two weeks

·         Topical Carboxymethylcellulose 0.5% (4-6 times a day) and ointment Hypromellose ( at bed time) depending on Bell’s phenomenon.

·         Ointment Tobramycin 0.3% for local application over wound for 10 days.

·         Skin suture removal will be done on day 10 post-op.

 

    FOLLOW UP

   Patients will be followed up to 6 months from the post-operative day1 (table 1).