Figure 7-25A and B.

The disinserted edge of the lower eyelid retractors is then reattached onto the
inferior border of the tarsal plate by using three sets of double armed 5-0 chromic sutures. These
sutures should be evenly spaced along the length of the lid. One arm of the suture is initially passed
horizontally through the retractors at the lower edge of the incision.

Figure 7-26A and B. While a tissue forceps is everting the infratarsal edge, the needle is passed
through the tarsus in a backhanded fashion. The second arm is passed about 5 to 6 mm from the
first in the same manner. After passing both arms of the suture, the suture is pully superiorly, joining
the edge of the retractors to the inferior tarsal border.

Figure 7-27A and B. With forceps grassping the conjunctival edge of the incision the needle is passed
deep into the inferior fornix, through the full thickness of the eyelid, to emerge from the skin surface
about 12 to 15 mm inferior to the lid margin.

Figure 7-28. The other arm of the suture is passed in the same fashion. The other two sets of suture
are passed 4 to 5 mm apart, in an identical manner to form three sets of evenly spaced sutures
across the lid.

Figure 7-29. The three sets of sutures are then tied on the skin surface, without the use f bolsters.
Upon tying of the sutures, there will be an immediate inversion of the lid margin. The suture should
not be tied so tightly that they overinvert the lid margin and produce entropion. To verify the proper
reattachment of the retractors to the tarsal plate, the patient is asked to look downward, and one
should see a smooth downdward excursion of the lower lid.

Figure 7-30. Sagittal view of the eyelid showing the path of the sutures. The looping passage of the
sutures induces a vetor force that pulls the tarsal plate downward and rotates the lid margin
posterioly. This inversion vector force counteracts any outward pulling effect imparted by the
anterior lamella. The subsequnt formation of an inflammatry cicatrix induced by the absorbable
sutures helps to maintain the eyelid in an upright posture. If comcomitant horizontal lid laxity is
present, a lateral tarsal strip procedure can be performed. Bacitracin ophtalmic ointment is apllied
on the suture knots and in the inferior fornix. The chromic sutures usually are absorbed within 10 to
14 days.

Chapter 8

Concentrically arranged fibers of the orbicularis oculi are innervated by cranial nerve (CN) VII to
affect narrowing of the palpebral fissure. Palpebral (pretarsal and preseptal) portions of the
orbicularis fibers are more involved in involuntary, fine eyelid blink movement, while the orbital
portion is responsible for forceful eyelid closure such as in a wink of blepharospasm. Proper eyelid
blink dynamics require the palpebral porrions of the orbicularis fibers to be firmly achored at the
medial and lateral canthal tendons (LCTs). This provides a tension-bearing anchoring fulcrum for the
contracting muscle fibers. Laxity in LCT anchoring renders the concentrically arranged orbicularis
fibers ineffective in completing the blink cycle.

Medially, the pretarsal orbicularis has two heads : one forms the anterior limb of the medial canthal
tendon (MCT), and the other, deeper head, is the tensor tarsi muscle of Horner forming the
posterior limb of the MCT. The lateral palpebral ligament (LCT) is formed by dense fibrous tissue
arising from the tarsi and the fusion of the pretarsal orbicularis muscle from the upper and lower
eyelids. Laterally, is passes deep to the orbital septum, inserting onto the lateral orbital tubercle 1,5
mm posterior to the lateral orbital rim. The tendon is approximately 10,5 mm in horizontal length
and 6,5 mm in vertical width. The midpoint of the LCT at the lateral orbital tubercle measures 10 mm
inferior to the frontozygomatic suture line. A small pocket of fat (Eisler pocket) lies between the
septu and the LCT. The LCT is also attached t the lateral orbital rim more superficially by Knize as the
superficial LC and may be used such as tension beariing structure to suspend or stabilize the lateral
canthus.

LCT disinsertion is a seldom recognized anatomical defect that can alter the mechanics of eyelid
blinking and lacrimal pump function. This often results in occular irritation and epiphora. The clinical
features of lateral canthal disinsertion are (a) blunted or vertically displaced lateral canthal angle, (b)
medial and inferior movement of the lateral commisure on dynamic eyelid closure, (c) incomplete
apposition of the eyelid margis on closure in the absence of anterior lamella shortage, (d) temporal
eyelid imbrication on attempted lid closure, and (e) pseudo upper eyelid retraction. Clinically, a
cotton tripped applicator can be used to distract the lateral commissure toward the lateral orbital
rim to stimulate tightening of the LCT. Improvement in blink dynamics and lid closure with this
simple maneuver verify that LCT disinsertion is the undelying anatomical element of pathology. The
cotton-tipped applicator test serves as a good predictor of fuctional outcome following LCT
tightening.

TECHNIQUE

The lateral cancthpexy technique begins with marking a planned horizontal incision along the lateral
canthus. Subcutaneous infiltration of lidocaine 2% with 1:100.000 dilution of epinephrine is
administered with a 30 gauge needle. The lateral orbital rim is palpated and a small amount of
anesthetic is also delivered to the periosteum of he lateral orbital rim and temporal inferior fornix.

Figure 8-1. a transverse skin incision is mde with a No.15 scalpel blade begining at the lateral
commissure and extends for 1.0 to 1,5 cm toward the lateral orbital rim. Hemostasis is achieved ith a
bipolar cautery. With fine, shallow movements of the scalpel blade, the circumferential orbicularis
muscle fibers are incised.

Figure 8-2. While grasping the skin-muscle layer with a forceps, sharp dissection with a Westcott
scissor is performed within the suborbicularis plane on both sides of the incision for 4 to 5 mm.

Figure 8-3AB. The whitish horizontal bands of the superficial LCT will become apparent. The superior
and inferior crus of the LCT can be identified at the temporal end the tarsal palte by bluntly
dissecting the pretarsal orbicularis from the underlying dense fibrous tissue connecting the tarsal
plate onto the Whitnall’s lateral tubercle within the lateral orbital rim.

Figure 8-4 Using double pronged skin hooks to retract the skin edges, the superficial LCT and the
underlying dense fibrous tissue superficial to the Eisler fat pad are grasped with a 0,3 forceps.
Tissues grasped by the forceps can be fied as superficial LCT by the omvement of the lateral canthal
angle with traction of the structure toward the orbital rim.
Figure 8-5ABCD The needle of a double-armed 5-0 Mersilene suture on an S-24 spatula needle is
passed under the entire width of the superficial LCT close to the lateral commissure in the manner of
passing a needle through a rectus muscle for the standard recession procedure (B,C). The suture is
tied to secure its engagement with the tendon (D).

Figure 8-6AB Instead of placing a secure locking bite at the tendon border, the needle engages the
dense fibrous superior crus (B)and secures it with a locking knot. The other needle engages the
inferior crus with a similar locking knot.

Figure 8-7ABC. Placement of locking knots reduces the likehood of suture cheese-wiring through the
tarsoligamentous sling (B,C).

Figure 8-8ABC. While exposing the needle exit point on the anterior suface of the lateral orbital rim
with a Freer periosteal elevator, the spatula needle aims at the Whitmll’s lateral tubercle on the
inner surface of the lateral orbital wall and passes under the periosteum to emerge from the
anterior surface of the orbtal rim. A Freer periosteal elevator retracts the tissues on the anterior
surface of the orbital rim to facilitate visualization of the emerging needle tip. The other needle of
the double armed nonasorbable suture is passed in a similar manner. A minimum of 4 to 5 mm of
periosteum must be engaged to minimize cheese-wiring and ensure firm fixaton. Firm passage under
the periosterum is verified by gentle traction on the suture.

Figue 8-9AB While pulling up on the sutures, a firm tie is applied to achieve a slight lateral
overcorrection, using both the periosteum and the superficial LCT as tension-bearing fixation
fulcrum. The vector of suture passage provides a posterior-laterally directed movement of the lateral
commissure while preserving its configuration and maintaining lid-globe apposition.

Figure 8-10 The skin incision is closed with interrupted sutures. To reduce the cost of the procedure,
the 5-0 Mersilense suture used for the canthopexy could be used for skin closure. The skin sutures
are removed in 5 to 7 days.

Figure 8-11. The illustration provides a comparison of the appearance of the tendon after tightening.

LCT disinsertion is an often unrecognized cause of symptomatic ocular irritation and epiphora. The
clinical triad of superficial lateral canthal disinserion consists of medial and inferior movement of the
lateral commissure on dynamic eyelid movement, incomplete apposition of the eyelid margins on
closure in the absence of anterior lamella shortage, and temporal eyelid imbricatio on lid closure.
This lateral canthopexy technique is a plication of the superficial LCT to the lateral orbital rim
perosteum. The suture locking of the superior and inferior cruses of the tendon in the manner of
securing a muscle in strabismus surgery minimizes cheese-wiring of tissues. This simple and effective
procdure is designed to improve blink dynamics by repositioning the lateral commissure and
restoring tension to the orbicularis fibers through firm LCT fixation.

CHAPTER 9

Acquired ptosis

Preoperative evaluation
The vast majority of cases of acquired ptosis are aponeurogenic. Nonetheless, the causes of acquired
ptosis are diverse, and it is helpful in evaluation and treatment to classify acquired ptosis into the
following : aponeurogenic, from involutional or other disinsertional changes in the aponeurosis :
myogenic, associated with decreased levator muscle function, as seen in myasthenia gravis or
congenital progressive external ophtalmoplegia (CPEO): neurogenic, as seen in third-nerve palsy or
Horner’s syndrome: and mechanical, associated with eyelid masses or scarring of the eyelid
lamellae. Traumatic ptosis may be considered a separate category, although it actually is a
subcategory of each of the fotegoing categories.

In the patient workup and evaluation, one must begin with a careful history, with attention to
duration and progression of ptosis, daily variation in the severity of ptosis and any history of dry eye
complaints. Examination should focus on determining the severity of ptosis, levator function, lid
crease height, and coexisting eye problems, such as lower eyelid retraction, overhanging skin on the
upper lid, or contralateral upper eyelid retraction, creating a pseudoptosis on the side in question.
Clinical features of a patient with acquired aponeurosis disinsertion consist of good levator function,
higher than normal eyelid crease, and a ptotic eyelid that assumes a lower position on down gaze. If
a history consistent with myasthenia gravis is suspected, tests for fatigability as well as an
edrophonium (Tensilon) test should be performed. The examiner should be cognizant of the
frequency of bilateral ptosis that is more apparent on one side. Because of the equal innervation to
both levator muscle, correcting only one upper lid may result in worsening the appearance of ptosis
on the opposite side. This phenomenon follows Hering’s law and is especially frequent in
aponeurogenic ptosis.

Indications for surgery

Adut ptosis is typically symptomatic, whether the complaints relate to visual obstruction or a tired,
inattentive appearance. A patient may also complain of forehead fatigue caused by constant brow
elevation in an effort to help lift a ptotic eyelid. If repair is being performed for functional indication,
it is vital to document the severity of ptosis with diagrams, facial photographs, and perimetry,
showing the superior visual field constriction produced by ptosis. It also helpful to have photographs
and notes available for reference at the time of surgery. A ptosis repair may be performed in most
patients at any time. After trauma, it is prudent to wait 6 months before ptosis repair, as function
may improve during that time. In myasthenia gravis, or any medical or neurologic condition that may
remit with therapy, it is wise to delat surgert until the condition is stable and optimally controlled.

Making procedural choices

With few exceptions, acquirred ptosis can be treated by an aponeurotic resection or repair. An
external aponeurotic approach directly treats the most common cause for aqcuires ptosis,
aponeurotic rarefaction or disinsrtion. Aponeurotic surgery is also preferred approach in myogenic
or neurogenic ptosis with adequate levator function.

The mullerectomu procedure described by Urist and Pustterman provides predictable correction of
ptosis based on response to a phenylephrine test in the ptotic eyelid. The simplicity of this
procedure and ability to perform formulac surgery predicted by a pharmacologic test make this
technique popular.
Frontalis suspension procedures (see section on congenital ptosis) may be requires in severe
neurogenic, myogenic, or traumatic ptosis with the loss of levator function. In acquired unilateral
ptosis with poor levator function, it is unnecessary to extirpate the contralateral levator and then
suspend both lids. It much easier for and adult without long-standing visual suppression to learn to
use brow function to help elevate a ptotic eyelid. When performing slig procedures or aponeurotic
surgery on individuals with ptosis associated with weak eyelid closure (CPEO, myasthenia gravis),
one must avoid overcorrection and exposure keratopathy.

Surgical procedure

Aponeurotic resection

The eyelid crease is generally marked along the entire eyelid to correspond with the natural skin
crease of the oppposite upper lid. In selected adult patients with good levator function, the repair
can be accomplished through a small central 12 to 15 mm incision. Anesthesia is obtained by
subcutaneous infiltration along the preplaced skin marking ith 0,5 to 1,5 ml of 2% lidocaine with
:100.000 dilution of ephinephrine. It is important not to inject too deeply into the eyelid, thereby
anesthetizinf Muller’s muscle, which can influence intraoperative lid height adjustments. Topical
tetracaine is instilled onto the cornea.

Figure 9-1. After subcutaneous infiltration, a 4-0 double-armed sil traction sutre is placed at the
central upper lid margin and secured t the sugical drape below with a hemostat. The suture is placed
through the gray line at the lid margin to avoid the marginal arcade, thereby preventing unnecessary
bleeding. When secure inferiotly, this traction suture puts all eyelid structures posterios to the
orbicularis muscle on tension, while allowing the anterior lamella to be mobilized. The skin is incised
aong the previously marked lid crease with a scalpel.

Fiure 9-2. The orbicularis is tented anteriorly with a toothed forceps, and its full-thickness is incised
centrally with a Westcott scissors oriented perpendicularly.

Figure 9-3. It is a key maneuver in this technique to make a full-thickness incision throgh the
orbicularis muscle, as this avoids unnecessary bleeding from multiple cuts into the muscle and
permits identification of the avascular posterior orbicular facial plane (needle).

Figure 9-4 One blade of scissors is then passed bluntly into the avascular plane, and the incision is
completed medially and laterally. The superior edge of the incision is retracted upward with a skin
hook, and the disinserted edge of the levator aponeurosis can oftentimes be identified through the
translucent postorbicular fascia. The postorbicular fascia is recognized as a delicate layer overlying
the aponeurosis. In this fascial plane, vertically oriented peripheral nerve fibers can sometimes be
seen. Further dissection is required to expose the levator aponeurosis.

While retracting the superior edge of the incision with a double-pronged skin hook, gentle pressure
is applied on the globe. With retrograde orbital pressure, the preaponeurotic fat pad budges forward
to tent up the orbital septum.
Figure 9-5. A horizonal incision is made with a Westcott scissors to buttonhole the orbital septum
above its fusion with the aponeurosis. The incision should be directed superiorly to avoid trensecting
Muller’s muscle or the conjunctiva. Yis allows tht preaponeurotic fat to herniate thrugh the
buttonhole. The entire orbital septum is then opened by placing one blade of he scissors behind the
orbital septum and extending the incision medially and laterally.

The foregoing maneuvers are important to identify the preaponeurotic fat pad and to avoid making
iatrogenic defects in the aponeurosis.

Figure 9-6 The skin and orbicularis muscle are retracted with forceps. The preaponeurotic fat pad
(indicated by the top needle) is the key anatomic landmark in this surgery, since the levator
aponeurosis located immediately beneath this structure (lower needle). Mulller’s muscle lies
immediately under the levator aponeurosis. In cases of repeated operation, trauma, or in eyelids
infiltrated by tumor, such as neurofibroma, the preaponeurotic fat pad may be the only identifiable
structure.

Figure 9-7. the preaponeurotic fat pad is refracted superiorly with a Desmarres retractor, and fine
attachments to the underlying levator aponeurosis are lysed with a Westcott scissors.

Figure 9-8. The disinserted edge of the levator aponeurosis is grasped with forceps. When the
patient is asked to look superiorly, the surgeon can feel the force generated againts the forceps,
confirming the structure to be aponeurosis. The Whitnall’s ligament can be seen at he superior limit
of the aponeurosis (needle tip). Frequently, the inserted edge of the aponeurosis can be recognized.

Figure 9.9 A strip of pretarsal orbicularis muscle, at the superior margin of the tarsus, is excised by
bluntly undermining wit a Westcott scissors, thus baring the anterior surface of the tarsal palte. In
ptosis cases in which the levator aponeurosis is intact, the appropriate amount of aponeurosis is
resected with Westcott scissors. In patents in whom a rarefaction or dehiscence of the aponeurosis
is present, it is important to excise the rareied area to create a free healthy muscle edge for achoring
onto the tarsal plate.

If the aponeurosis has been disinserted, the disinserted edge is grasped with a forceps and sutured
to the nterior surface of the tarsal palte. If there has been no obvoius disinertion, the aoneurosis is
then detached from the upper border no obvious disinsertio, the aponeurosis is then detached from
the upper border of te tarsal plate. The peripheral vascular arcade in Muller’s muscle helps to
identfy this strctre. If bleeding occurs in this plane, one should pick up the tissue with the bipolar tip
before cauterizing, thereby preventing thermal injury to the underying cornea.