Surgical methods in the treatment of blepharoptosis

Abstract

Introduction: Blepharoptosis is a drooping of the upper eyelid causing a narrowing of the palpebral aperture, may be divided in two main types: congenital and acquired. An actual problem, that may affect the patients in all periods of ages. The most problematic are the ptosis of the children, which may develop amblyopia or astigmatism, when ptosis isn’t treated surgically in time. At the moment there are more that 150 surgical methods of plastic surgery of the upper eyelid in congenital and acquired ptosis. The correct choice of a method depends on basic criteria: the cause of ptosis, patient’s age, ptosis’ degree, the fuction of levator muscle, specific parameters (like MRD) and influence on the efficiency of the intervention result of, aesthetic effect, minimal postsurgical complications and gut therapeutic effect (in amblyopia cases by children). Presently, there are not any schemes of efficient approach to the patient with blepharoptosis, which help to choose a correct surgical method with a good cosmetic, fuctional effect. Objectives: To elaborate the schemes of surgical treatment for each cause group of blepharoptosis. To introduce a new surgical method in Moldova of Kataew (appeared in 2008, Nr.of patent №2008143463) in congenital blepharoptosis with very low fucntion of levator muscle in children. To appreciate the results of surgical treatment according to the proposed scheme. Methods: The work was effectuated in the clinical base of ophthalmology of USMF, medical particular ophthalmological center „Ovisus”, Municipal Clinical Hospital №1. There were examined 31 patients from 4-73 years, who were operated from 2003-2011. Four of the most perspective methods - Miillerorafia (advancement of Midler muscle), Frontal suspension (connection between tarsus and frontal muscle with alloplastic material (mersilen, silicon) in pentagon form), new Kataew method (upper lid suspension to ligament of Whitnall) and Elsching method (orbico-frontal adherence to eyebrow upper suspention approch) were used from the spectrum. Results: The majority (60% of the cases) are present with congenital ptosis of different degree. Traumatic and involutive ptosis predominate from the last 40%. A correlation between LF(levator function) and MRD (marginal reflex distance) is found, as MRD is lower, which speaks of a bigger degree of ptosis, so the levator muscle function is weaker. The most representative was congenital ptosis in children (4-12 years) with MRD -1,5 mm media and LF 2 mm( II-IV degree of ptosis). In such cases, according to the scheme, Kataew-method, with growind MRD +2,5 mm in media (+4mm norm) and LF 8 mm (10-15 mm norm) were efectuated. Miillerorafia was a method of choice for the patient with congenital ptosis of the 1st degree and involutive ptosis, with the obligatory condition of satisfactory function of Miiller muscle. The testing of it’s function was effectuated by the help of phenylephrine (mesaton) 2,5% test (positive when MRD grows with 1,5-1,8 mm after 10 min of dropping in eyes.) 4 patients were operated. According to the scheme, the patients with congenital ptosis I and II degree and negative mesa ton test, Elsching operation is the method of choice, which was the most used - 11 patients. Frontal suspension as an alternative method in severe ptosis and as reoperation variant (as reoperation by 2 patients with traumatic ptosis in 2003,2 004). According to the postoperative criteria, pre- and postoperative MRD have a difference in 3,1 mm media (preoperational MRD +0,5 and postoperational MRD +3,64 in media). Also LF increased from 4,66 mm pre- till 7 mm postoperative in media. Conclusions: Using proposed scheme an appropriate method of ptosis correction intervention could be chosen. In congenital ptosis of high degree with a low LF, Kataew method of operation can be successfully implemented. Miillerorafia gives positive results only for phenilephedrine positive test in involutive ptosis or congenintal of low degree. In phenilephedrine negative test for congenital ptosis higher degree frontal suspention or Elsching method could be used.