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Scissors Ophthalmic
Radiosurgically assisted small-incision ptosis correction
Also in ophthalmology there is a trend toward minimally invasive surgery. Advantages of small-incision surgery are (among others) : decreased morbidity and faster return to work, decreased operative time (…and thus less infection), rapid healing with less and less visible scarring. Moreover, radiosurgery offers nicer dissection with less bleeding and reduced edema. As with all ptosis surgery, local anaesthesia is preferable because it allows a more accurate position of the eyelid and the lid crease.
Especially in ptosis surgery a careful evaluation of the patient is essential. And the evaluation starts with the history of the ptosis: in case of a contenital ptosis (a ptosis that was already present at birth) we are dealing with a bad muscle and a (slight) over-correction will be necessary to achieve an acceptable result. Moreover, in these cases there will be a bigger risk for asymmetry needing a second correction.
Also a differential diagnosis between a true ptosis and a dermatochalazis : an excess of skin that can push the eyelid down to cause a pseudoptosis or ‘false' ptosis. And a ptosis that varies from hour to hour suggests a illness of the muscle. And a diplopia must force the ophthtalmologist to search for an neurological cause of the ptosis.
Most of the time a ptosis is bilateral but not symmetrical: when a patient has difficulty to lift his eyelids he will use his frontalis muscle to compensate it. Unilateral surgical correction will make the patient relax both frontalis muscles after the surgery leading to a contralateral ptosis and a unhyappy patient!
And last but not least we must be awere, both in patients with ptosis as with dermatochalazis that also a brow ptosis is very frequent. When this brow ptosis is not corrected, correcting the upper lid alone will even accentuate the brow ptosis by pulling it downwards.
In fact a complete ophthalmic examination is appropriate prior to ptosis surgery. We have to pay special attention to a pre-existing dry eye. For patients with a dry eye a ptosis can even be beneficial since it diminishes the evaporation of tears. In dry eye patients even a small or temporary lagophthalmos (when the eye does not completely close during the night or when blinking) can be threatening for the cornea!
The small incision ptosis correction is especially useful for those patients with only limited dermatochalazis and still a relatively good levator muscle function.
Before infiltration of the eyelid with an anaesthetic solution the lid crease is marked with a surgical marking pen. A very superficial skin incision of 8 to 12 mm is made with the radiosurgery unit in the cutting mode that delivers 90% of cutting effect and 10% of coagulation. Then we switch to a cut/coagulation mode with 50% cutting and 50% of coagulation to cut through the orbicularis muscle and to expose the superior half of the tarsus. A careful dissection is performed until pure tarsus is seen. Then the assistant is asked to provide a gentle traction to the pretarsal orbicularis caudally and at the same time the surgeon grasps the preseptal part of the muscle superiorly. The levator aponeurosis will become visible as a whiter structure under the orbicularis muscle. An incision is made at the fusion of both layers. Especially in younger patients the preaponeurotic fat pad can become visible and serves as a landmark to identify the aponeurosis. With curved scissors a blunt dissection is performed to liberate the aponeurosis from orbital septum and fat pad.
A double armed 5/0 Polyglactin suture is passed two times through the partial thickness of the tarsus in a U-shape, goes underneath the aponeurosis and is retrieved anteriorly at the desired height. A preliminary knot is made to avaluate the position of the lid margin with the patient in upright position keeping in mind that the lids are somewhat paralysed because of the anaesthesia and might be heavier with some edema.
Also the lid lag is evaluated by asking the patient to look down. Not only an overcorrection but also an insufficient blunt dissection of the levator aponeurosis can give a lid lag!
When the result is ok, the polyglactin suture can be tied. The orbicularis muscle can be
About the Author
Dr. Peter Raus is an internationally known oculoplastic surgeon. He is the owner of the Miró Center for oculoplastic surgery in Mol, Belgium. Peter already gave lectures on oculoplastics in 23 different countries. He is the inventor of the Raus clamp for ectropium surgery. Dr. Raus is also a columnist for the magazine 'Living in Style'.
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