SURGICAL TREATMENT O F TRAUMATIC BLEPHAROPTOSIS

RAYNOLD N.

Palo Alto,

The surgical treatment of acquired bleph­aroptosis is more complex and the results less predictable than that of congenital blepharop­tosis. This is especially true of the traumatic cases; they are relatively rare and no two cases are identical.

INCIDENCE OF TRAUMATIC BLEPHAROPTOSIS

Less than 2% of all major ophthalmic op­erations are for blepharoptosis.1 Reports2-5

show that tramua was the indication in only 9% of 1109 operations for blepharoptosis (Table 1), and since the incidence of trau­matic blepharoptosis is so very low, it is un­likely that any one surgeon can collect enough such cases during an entire lifetime to formulate reliable guidelines for surgical treatment. Nevertheless, I shall propose a simple formula for avoiding gross amounts of overcorrection or under correction after an external levator resection operation. I shall also show the results of this and other blepharoptosis operations for this condition when trauma is causative.

A simple classification of the various causes of acquired blepharoptosis is given in Table 2, based on the reports of the investi­gators cited in Table 1. In 101 consecutive cases of acquired blepharoptosis, trauma (Table 3) was the most common single cause.

MATERIAL AND METHODS

Surgery was performed on 40 patients with unilateral traumatic blepharoptosis. An internal approach was used in 11 cases and an external approach in 26 in order to re­trieve a severed levator muscle or to resect an intact one. A Berke-Motais6 or a Craw­ford7 operation was performed on three eye­lids with no levator function, with disap­pointing results.

Reprint requests to Raynold N. Berke, M.D., 2275 Sharon Road, Menlo Park, California 94025.

B E R K E , M.D.

California

When trauma is causative, other problems often complicate the correction of the bleph­aroptosis. In the present series, these problems consisted mainly of a gross hypo-tropia (15 cases), adhesions between the leva-tor muscle and the globe (three cases), or between the upper eyelid and the superior orbital margin (three cases), and there may be other assorted problems resulting from previous unsuccessful attempts to repair the blepharoptosis. Some of these complications could be corrected along with the blepharop­tosis, but others were insurmountable.

BLEPHAROPTOSIS CAUSED BY SURGICAL TRAUMA

In 72% of the patients, blepharoptosis de­veloped after an operation on the orbit, the upper eyelid, the globe, or one of the extra-ocular muscles.

After orbitotomy—A transcranial or a lat­eral orbitotomy caused blepharoptosis in eight patients, most of whom had a good re­sult from a levator resection operation when the levator function was 6 mm or more (Fig. 1). But when the levator muscle was para­lyzed, this operation failed. Consequently, such eyelids had to be suspended from the frontalis muscle with a less satisfactory re­sult (Fig. 2 ) .

After enucleation—Eight patients had 2-8 mm of unilateral blepharoptosis and an in­tact levator muscle after an apparently un­complicated enucleation. Seven of these had 5-12 mm of true levator function,* and these were adequately corrected by either an inter­nal8 or by an external9 levator resection (Fig. 3) . In order to prevent final over- or

* True levator function occurred when the upper eyelid was elevated only by the levator muscle. The levator function was false when adhesions between the levator and the globe caused the eyelid to be elevated by the superior rectus muscle rather than by the levator.

692 A M E R I C A N J O U R N A L O F O P H T H A L M O L O G Y OCTOBER, 1971

TABLE 1

INCIDENCE OF SURGICALLY TREATED BLEPHAROPTOSIS

Author

Johnson2

Hamilton* Beard4

Smith' Present series

Total

No. Cases

108 41

140 148 672

1,109

Congenital

85 (79%) 26 (63%) 89 (64%) 99 (67%)

571 (85%) 870 (78%)

Traumatic

9 (8%) 6 (15%)

16(11%) 28 (19%) 40 (6%) 99 (9%)

Acquired

Nontraumatic

14 (13%) 9 (22%)

35 (25%) 21 (14%) 61 (9%)

140 (13%)

undercorrection, each of these seven eyelids was positioned on its prosthesis at operation so as to compensate for a greater postopera­tive "lift" of the eyelid when the levator function was 8 mm or more than when it was only 5 mm. If a small amount of postopera­tive over- or undercorrection occurred, these defects could be reduced by ordering a new prosthesis of the proper thickness or by hav­ing the cornea of the prosthesis moved up­ward or downward to compensate for the over or undercorrection. Thus, a pleasing re­sult (Fig. 4) could be achieved without addi­tional surgery.

The eighth patient had 8 mm of blepha­roptosis with no levator function after a long section of the optic nerve had been excised during an enucleation for retinoblastoma. Because the levator muscle was paralyzed, a subsequent levator resection failed to reduce the blepharoptosis. In this case, a Crawford7

operation may have yielded a more accept­able outcome.

After operation on conjunctiva—Seven patients developed 2-12 mm of blepharopto­sis after a subconjunctival tumor or cyst had been excised from the globe or from the up­per eyelid. In each case the levator tissues above the tarsus had been injured; conse­quently, the levator function measured only 3-6 mm in three cases and 7-12 mm in the other four.

In five of these seven cases, the retracted end of the severed levator muscle was found through a skin approach and then reattached to the tarsus. When last examined an aver­age of 30 months postoperation, four cases were fully or almost fully corrected (Fig. 5). A conjunctival approach was employed

TABLE 3

CLASSIFICATION OF CAUSES OF 40 CASES OF TRAUMATIC BLEPHAROPTOSIS

TABLE 2

CLASSIFICATION OF 101 CASES OF ACQUIRED BLEPHAROPTOSIS

Cause No. Cases)

Classification

Trauma Idiopathic Blepharochalasis Progressive external ophthalmoplegia Tumors of upper eyelid Horner's syndrome Systemic disease Microphthalmos

Total Incidence

40% 2 3 %

9% 9 % 8% 5 % 5 % 2 %

Surgical trauma Orbital Operations Enucleations Conjunctival and eyelid operations Operations on superior oblique muscle Operations on lateral rectus muscle

Total Nonsurgical trauma

Toy, stick, sled, football, golf club Beer bottle, auto accident, fall Bullet through orbit

Total

7 4 2

29 (72%

5

11(28%)

VOL. 72, NO. 4 TRAUMATIC BLEPHAROPTOSIS 693

Fig. 1 (Berke). Traumatic blepharoptosis caused by enophthalmos after Kronlein operation. Left: Before external levator resection. Right: Three years after operation.

Fig. 2 (Berke). Traumatic blepharoptosis caused by injury to third nerve during Kronlein operation. Left: After a Friedenwald-Guyton and two levator resection operations. Right: Twenty-one months after a Crawford operation.

in two of the seven cases, but the retracted levator tissues could not be found by this technique; consequently, both were found to be much undercorrected months later.

When the external approach was em­ployed to retrieve a severed levator muscle, an intact medial or lateral horn usually lead the surgeon to the retracted end of the mus­

cle. But when both horns had been severed and the levator had receded out of sight into the epibulbar tissues, the lost levator could be found and identified only by grasping and pulling these tissues forward on a blepharop­tosis clamp while the surgeon palpated the trochlea for Whitnall's check ligament. If the levator had been caught in the clamp, the surgeon would feel a cord-like band (Whit­nall's ligament) extending from the trochlea towards the clamp. By this means the sur­geon could find a lost levator and free it from the surrounding tissues without jeop­ardizing the underlying superior rectus or the superior oblique tendon.

When repairing this kind of blepharopto­sis, the surgeon must realize that the postop­erative lift of the eyelid will be greater when the levator action is good than when it is poor. In other words, he must position the blepharoptotic eyelid on its cornea at opera­tion so as to fully compensate for this post­operative lift.

Fig. 3 (Berke). Traumatic blepharoptosis caused by enucleation. Left: Before external levator resec­tion. Right: Eight months after operation.

Fig. 4 (Berke). Traumatic bleph­aroptosis caused by enucleation. Left: Before external levator re­section. Center: Three months after operation with preoperative pros­thesis in place. Right: Six months after blepharoptosis operation with new prosthesis.

694 AMERICAN JOURNAL OF OPHTHALMOLOGY OCTOBER, 1971

Fig. S (Berke). Traumatic blepharoptosis caused by excision of dermolipoma. Top: Position of tumor before excision. Left: Blepharoptosis after excision of tumor. Right: Two months after external levator resection.

After extraocular muscle operations— Two patients developed 3-5 mm of blepha­roptosis after a strabismus operation had se­vered the latter horn of the levator aponeu­rosis. Both blepharoptotic eyelids were cor­rected by advancing the severed aponeurosis to the upper tarsus by an external (Fig. 6) or by an internal approach (Fig. 7).

Four other patients developed an uncom­promising type of blepharoptosis after an operation on the superior oblique tendon. In each case, the superior rectus had been sev­ered from the globe in a prolonged and ex­tensive search for the superior oblique ten­don. So much excessive manipulation of the epibulbar tissues caused dense postopera­tive adhesions between the globe and the trochlea, and also between the levator muscle and the superior rectus. Consequently, each patient developed a spurious type of levator function, in which the blepharoptotic eyelid

was elevated from downgaze to upgaze more by the superior rectus muscle than by the levator muscle. In such cases, a levator resec­tion operation was most difficult and unpre­dictable, not only because the adhesions bound the levator to the superior rectus mus­cle, but also because the adhesions reformed —even when such inert materials as Gel-foam, Gelfilm, silicone rubber, or Supramide Extra had been placed under the levator to prevent their reformation.

Figure 8 illustrates one of the better cos­metic results obtained in one such case after two external levator resections. The blepha­roptosis was well corrected, but the patient had to keep her eyelids taped together during

Fig. 6 (Berke). Traumatic blepharoptosis caused by recession of external rectus muscle. Left: Before external levator resection. Right: Six weeks later.

Fig. 7 (Berke). Traumatic blepharoptosis after resection of left external rectus. Left: Before in­ternal levator resection. Right: Three months after­ward.

VOL. 72, NO. 4 TRAUMATIC BLEPHAROPTOSIS 695

Fig. 8 (Berke). Traumatic blepharoptosis caused by tenotomy operation on left superior oblique. Far left: Three months after Friedenwald-Guyton operation. Center left: Six months after first external levator resection. Center right: Two months after second external levator resection. Far right: Three years after excision of redundant upper lid skin.

sleep for months to prevent postoperative exposure keratitis.

Another patient had blepharoptosis and le-vator-to-globe adhesions after an operation on the superior oblique tendon. She had a fascia lata frontalis operation with an out­come (Fig. 9) even worse than that shown in Figure 8

BLEPHAROPTOSIS CAUSED BY NONSURGICAL

TRAUMA

Nonsurgical trauma caused blepharopto­sis in 11 patients. Ten experienced upper eyelid trauma, and in one, the blepharopto­sis resulted from a self-inflicted bullet wound to the orbit. When these patients were examined months or even years after the initial trauma, the degree of blepharopto­sis varied from 2 to 7 mm and the levator function from 3-10 mm.

In nine of the 11 patients the levator tis­

sues had been severed above the tarsus. Some of these had obvious scars only on the underside of the lid—an observation com­pletely missed by the examiner at the time of the initial repair. Another patient, whose blepharoptosis occurred after a blunt football injury, had no visible scars whatever on ei­ther surface. These observations indicate that we must examine both sides of the upper eyelid when repairing face lacerations.

A n external approach was employed in eight of these 11 patients to find the re­tracted end of the severed levator tissues. After exposing the epibulbar tissues and ro­tating the globe downward, a thin layer of scar tissue or an intact medial or lateral horn usually guided the surgeon to the retracted end of the severed levator. But when the le­vator had retracted into the thick epibulbar tissues, it had to be retrieved by pulling the epibulbar tissues forward on a blepharoptosis

Fig. 9 (Berke). Traumatic bleph­aroptosis caused by resection of right superior oblique tendon. Left: Before Berke-Motais operation. Center: Before Crawford opera­tion. Right: One year later.

696 AMERICAN JOURNAL OF OPHTHALMOLOGY OCTOBER, 1971

Fig. 10 (Berke). Traumatic blepharoptosis due to eyelid laceration by sled runner. Left: Two months after accident. Right: Six months after external levator resection. Note overcorrection.

clamp as previously described. By this ma­neuver, the surgeon could find the lost levator and reattach it to the tarsus.

Since the surgeon could rarely identify the exact end of the levator muscle, especially when it was imbedded in the epibulbar tis­sues, he had to decide whether to shorten the levator and risk final overcorrection (Fig. 10), or to merely advance it to the tarsus and chance getting final undercorrection (Fig. 11). Consequently, two of these nine pa­tients required a subsequent levator resection (including patient shown in Fig. 11), while others needed a levator recession operation before a satisfactory outcome could be achieved. Until reliable guidelines become available, it seems wise to err on the side of overcorrection rather than undercorrection. The most important thing is to find the leva-tor, and then aim for overcorrection, since receding the levator is less difficult than re­secting the muscle for undercorrection.

The 11th case was a 53-year-old man who

had 6 mm of blepharoptosis after a bullet in­jury to the right orbit. Examination years later disclosed 7 mm of levator function, a blind right eye, 30 prism diopters of right hypotropia, an atypical von Graefe sign, and corneal anesthesia.

Even after he had been alerted to the dan­ger of postoperative keratitis, this patient was eager to have the blepharoptosis re­paired because it was a source of embarrass­ment to him at his job.

At operation the right inferior rectus was receded for the hypotropia, and the levator was resected for the blepharoptosis. Two weeks later both appeared well corrected, and the cornea was clear. But in the ensuing weeks an intractable neuroparalytic keratitis developed, despite local treatment and inter-marginal adhesions. At the patient's sugges­tion the eye was enucleated three months af­ter the blepharoptosis operation. With a prosthesis in place, the blepharoptosis was fairly well corrected, but the final outcome was unsatisfactory (Fig. 12).

In retrospect, I believe this patient would have had a better result if a thick Gunderson flap had been turned down over the cornea10

and a thin custom-made cosmetic shell fitted over the flap.

The final results of these 40 operations were appraised from one month (three cases) to 78 months (one case) after opera­tion, the average being 19 months.

DISCUSSION

An internal approach to the levator yielded a good result only when the levator

Fig. 11 (Berke). Traumatic blepharoptosis due to subconjunc-tival laceration of upper eyelid by golfer's putter. Left: After acci­dent. Center: Undercorrection 10 months after external levator resec­tion. Right: Six months after sec­ond external resection.

VOL. 72, NO. 4 T R A U M A T I C B L E P H A R O P T O S T S 697

Fig. 12 (Berke) . Traumatic blepharoptosis caused by bullet in­jury to right retrobulbar tissues. Left: Before external levator re­section. Center: Corneal ulceration three months later. Right: Six months after enucleation.

function was more than 5 mm from down-gaze to upgaze and the levator muscle was intact. An external approach usually gave better results when the levator function was less than 5 mm, or when the levator tissues had been severed above the tarsus. It was the operation of choice when the levator func­tion measured 3 mm or more from downgaze to upgaze. This was so mainly because the external approach gave better exposure of the epibulbar tissues.

Since reliable guidelines for the correction of such cases were unavailable, 20 of the 26 external operations were analyzed to evolve a provisional formula for avoiding gross amounts of postoperative overcorrection and undercorrection by this procedure. Only two of these 20 blepharoptotic eyelids "fell" postoperatively. (An eyelid was said to have fallen when it covered more cornea postoper­atively than it did at the end of operation. A postoperative "lift" occurred when the eyelid covered less cornea postoperatively

than at the end of operation. Since the other 18 eyelids registered a greater postop­erative "lift" when the levator function was good than when it was poor, the proposed guidelines were based on these observations.

These guidelines showed that the surgeon must position the blepharoptotic eyelid at operation so as to compensate for a greater postoperative lift when the preoperative lev­ator function is 8 mm or more than when it is 5 mm or less. For example, if the normal eyelid covered its cornea 2 mm in the pri­mary position (called the target area), and if the levator function indicated a postoperative lift of 4 mm, then the blepharoptotic eyelid should be raised at operation to cover its cor­nea 5 mm (3 mm below the target area) in order to offset a postoperative lift of 4 mm which would result in 1 mm of overcorrec­tion.

Unfortunately, the 20 cases analyzed failed to provide enough data on which to calculate the amount of lift for each degree

TABLE 4

GUIDELINES FOR CORRECTION OF TRAUMATIC BLEPHAROPTOSIS BY EXTERNAL APPROACH

Levator Function

3-4 mm 5-6 mm 7-8 mm 9-10 mm 11-12 mm

Target Area*

— 2 mm — 2 mm — 2 mm —2 mm — 2 mm

Eyelid Positionf at Operation

— 2 mm —3 mm —4 mm — 5 mm —6 mm

Postoperative Lift of Eyelid

1 mm 2 mm 3 mm 4 mm 5 mm

Amount of Overcorrection

1 mm 1 mm 1 mm 1 mm 1 mm

* Target area is the position of normal eyelid below the upper limbus in primary position. t Position of blepharoptotic eyelid below the upper limbus a t the end of operation with cornea in pri­

mary position.

698 A M E R I C A N J O U R N A L O F O P H T H A L M O L O G Y OCTOBER, 1971

of levator function. Therefore, the guide­lines in Table 4 are based upon extrapola­tions and can serve only as gross approxima­tions for preventing large amounts of over-or undercorrection when an external ap­proach is used. Table 4 may save the surgeon much guesswork when using an external ap­proach for this type of blepharoptosis. These data are useful only when the levator and the orbicularis muscles are relaxed under deep surgical anesthesia. Moreover, they are de­signed to give over- rather than undercorrec­tion for the reasons already mentioned.

SUMMARY

The surgical results in 40 patients with traumatic blepharoptosis were examined to ascertain which type of operation gave the best results. An external (skin) approach gave better exposure and yielded better re­sults than an internal (conjunctival) ap­proach for retrieving a retracted levator sev­ered in the eyelid. These operations, how­ever, were useless when the levator muscle was paralyzed. In such cases the blepharop-totic eyelid had to be suspended from the frontalis or from the superior rectus muscle with, however, a less satisfactory outcome.

A Crawford fascia lata operation is indi­cated for patients with unilateral traumatic blepharoptosis only when the levator muscle is paralyzed. The external approach is the procedure of choice for retrieving a severed levator muscle when the levator function is 3

mm or more from downgaze to upgaze. Gross amounts of over- or undercorrection can be avoided by this approach only when the surgeon positions the blepharoptotic eye­lid on its cornea at operation so as to com­pensate for a greater postoperative lift of the eyelid when the levator function is good than when it is poor.

REFERENCES

1. Berke, R. N . : Blepharoptosis. Arch. Ophth. 34:434, 1945.

2. Johnson, C. C.: Blepharoptosis: A general consideration of surgical methods, with results in 162 operations. Am. J. Ophth 38:129, 1954.

3. Hamilton, R. S.: Blepharoptosis, congenital and acquired. Relationships of anatomy and patho­logic physiology to surgical correction. Am. J. Ophth 49:337, 1960.

4. Beard, C.: The surgical treatment of blepha­roptosis: A quantitative approach. Tr. Am. Ophth. Soc. 64:401, 1966.

5. Smith, B., McCord, C. D., and Baylis, H . : Surgical treatment of blepharoptosis. Am. J. Ophth. 68:92, 1969.

6. Berke, R. N . : An operation for ptosis utilizing the superior rectus muscle. Arch. Ophth. 42:689, 1949.

7. Crawford, J. S.: Repair of ptosis using forn-talis muscle and fascia lata. Tr. Am. Acad. Ophth. Otolaryng. 60:672, 1956.

8. Berke, R. N . : A simplified Blascovics opera­tion for blepharoptosis. Results in 91 operations. Arch. Ophth. 48:460, 1952.

9. Berke, R. N . : Results of resection of the leva-tor muscle through a skin incision in congenital pto­sis. Arch. Ophth. 61:177, 1959.

10. Gunderson, T. : Conjunctival flaps in the treatment of corneal disease with reference to a new technique of application. Arch. Ophth. 60:880, 1958.