ORIGINAL ARTICLE

Sutureless Levator Plication by Conjunctivai Route A New Technique

DALJIT SINGH, MD, APJIT KAUR, MD, KIRANJIT SINGH, MD, SEEMA K. SINGH, MD, RAVI S.J. SINGH, MD.

ABSTRACT

The experiences of sutureless levator plication by con- junctival route surgery are described in 80 primary opera- tions performed for all grades of congenital ptosis in the past 2 years. The surgical steps, postoperative care and postoperative complications are reviewed.

REPRINTS Dr. Richard Fugo, Fugo Eye Institute, 100 W. Fornance, Norristown, PA 9401. E mail: RJFugomd@fugoblade.com

Drs. D. Singh, A. Kaur, K. Singh, S.K. Singh, and R.S.J. Singh are from the Dr. Daljit Singh Eye Hospital, Amritsar, India

DISCLOSURE The authors have stated that they do not have a significant financial interest or other relationship with any product manufacturer or provider of services dis- cussed in this article. The authors also do not discuss the use of off label prod ucts, which includes unlabeled, unapproved, or investigative products or devices.

Submitted for publicalion: 7/27/06. Accepted: 9/8/06.

Annals of Ophthalmology, vol. 38, no. 4, Winter 2006 �9 Copyright 2006 by ASCO All rights of any nature whatsoever reserved. 1530-4086/06/38:285-292/$30.00. ISSN 1558-9951 (Online)

I N T R O D U C T I O N

Bowman, in 1857, was the first to perform shortening of the levator muscle by the conjunctival route. Blaskovics (1923) described levator tendon shortening with resec- tion of upper portion of tarsus, via conjunctival route

(J). Agatson (1942) modified the operation as follows. The upper lid is everted and the upper border is fixed with a traction suture. The tarsus is incised 3 m m below

the upper border and pretarsal space is reached. Under- neath is levator aponeurosis. The aponeurosis is under- mined with scissors to be replaced by a ptosis clamp or a straight hemostat, which is tightened. The attachment of the Muller muscle is severed from the tarsal edge. A strip of tarsal plate is excised. The clamp is turned

down to align with the levator. The structures in the clamp are incised to sever their terminal attachments. Traction is made on the levator that is then freed from

its a t tachments to the orbital septum. The levator is freed in the orbit with blunt dissection. The levator is then totally freed from the orbital septum. The medial

and the lateral horns are snipped, and the muscular leva- tor is delivered up to 25 mm as needed. Three mattress sutures are passed through aponeurosis or the muscle at

predetermined levels above the clamp; they are then passed through the earlier undermined palpebral con- junctiva. The excess levator and Muller ' s muscle are

excised about 2 m m from the suture line. The sutures

are then carr ied through the upper tarsal edge and through the full thickness of the lid to crease level and

tied over a bolster of rubber band. A Frost suture is applied (3).

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Figure 1--The lid has been double everted by Desmarre's lid retractor.

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Figure 3--The conjunctiva has been ballooned.

Figure 2--Three stout nylon sutures have been passed through the upper edge of the tarsal plate.

Since 2004, we have been performing levator plication from the conjunctival route in an entirely different manner. In this technique the levator is picked up from the depth of the fomix and attached at three points, to the anterior sur- face of the tarsal place, without the need for extensive dis- section or excision of tissues. The closure is sutureless. The operation is done only as a primary procedure.

STEPS OF O P E R A T I O N

General anesthesia is preferred in all pediatric and most adult patients because it gives maximum relaxation of the tissues.

The steps of surgery are as follows: 1. The lid is double everted with a Desmarre's lid

retractor (Fig. 1). 2. Three stout nylon sutures are passed through the

upper edge of the tarsal plate (Fig.2).

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Figure 4--Three vertical incisions from the fornix to the upper edge of the tarsal plate have been made with the Fugo Blade. Notice the bleeding that started from the needle used to balloon the conjunctiva. This bleeding shall be observed throughout the procedure.

3. The conjunctiva is ballooned by the injection of lidocaine with epinephrine. Sometimes the needle prick causes unwanted bleeding under the conjunctiva. To avoid this, a thin cannula is used to inject the fluid from the edge of the nylon suture entry point (Fig.3).

4. Three vertical incisions are made in the ballooned conjunctiva starting from the fornix and reaching the entry points of nylon sutures. These incisions are of con- junctival depth, meant to expose the underlying Muller's muscle. They are preferably made with the Fugo Blade that incises/ablates without charring and shrinkage of the tissues. The blade is used at low power and moved slowly. Quick movement causes tearing of the tissue plus bleeding. Any oozing point is touched with the Fugo Blade to stop bleeding. We have not used radio- cautery or forceps scissors to create the incisions, since the former can cause charring and the latter can cause

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Figure 5---The process of undermining of the conjunctiva with Fugo blade.

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Figure 7--Levator muscle covered with orbital septum has been brought out of the fornix, by following the surface of Muller's muscle.

Figure 6---The anterior surface of the tarsal plate has been exposed close to the nylon traction sutures.

bleeding. Any amount of bleeding makes the perfor- mance of the succeeding steps more difficult (Fig.4).

5. The conjunctiva is undermined on all sides of the incisions so as to free it f rom Muller 's muscle. The undermining is also done toward the fornix over the sur- face of Muller's muscle toward the levator muscle. The undermining is bloodless with a flat-tipped Fugo Blade. It can also be done with a blunt scissors, especially toward the orbit. A scissors dissection is faster, although bleeding can sometimes spoil the show (Fig. 5).

6. The anterior surface of the tarsal plate is exposed for about 5 mm, starting from near the nylon traction suture. This is comfortably accomplished with a flat tip on the Fugo Blade at low energy settings. The tissues are ablated gradually from the surface downwards until the white surface of the tarsal plate is exposed. Three such areas are exposed (Fig. 6).

7. To find the levator muscle, a corneal forceps is introduced under the conjunctiva over the surface of the Muller 's muscle, which is fol lowed toward the orbit.

Figure 8--The central part of the levator muscle has been fixed to the anterior surface of the tarsal plate with 80-micron steel suture.

The continuation of the Muller's muscle, which is the levator muscle, is picked up and pulled out in the surgi- cal field. This is the anterior surface of the levator mus- cle, which is seen covered with the tissue of orbital septum. For this reason it looks white (Fig. 7).

8. To secure the levator muscle, we use an 80-g vana- dium steel suture for this purpose. The site of the levator that is caught depends on the degree of ptosis. The greater the ptosis, the deeper the point in the orbit from where the muscle should be engaged. We are in the process of developing a nomogram to define the point of engagement of the levator muscle. The suture is passed under the muscle twice to make a secure hold. A knot may be made, if desired (Fig. 8).

9. Fixing the levator to the anterior surface of the tarsal plate. The passage of the needle through the tarsal plate is made at half thickness. Before it makes a complete

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10. Closing the eye with a suture. We tie the two lids together, by passing a stout nylon suture through the skin of the upper and lower lids not far from the lid margin (Fig. 10).

Before the suture is tied, antibiotic eye ointment is placed on the eye. The suture is removed after 1 day in the adults and after 2 days in the case of children. The closing suture takes away the worry of protecting the cornea in the early postoperative period. During this period, the lid edema also gets considerably reduced. No lid suture is required when surgery is done for slight ptosis.

F i g u r e 9--The levator has been fixed on three points on the anterior surface of the tarsal plate.

P O S T O P E R A T I V E M A N A G E M E N T

Oral antibiotics are given for the first 4 days. Anti- in f lammatory drugs by mouth are not needed. The restraining nylon suture is cut after one or two days. The local medications are artificial tears six to seven times a day and antibiotic-steroid ointment BID for 2 weeks. The movement of the lid is observed in normal blinking and squeezing. The patient and the parents are advised to take care that sufficient blinking is done to prevent drying up of the cornea. The cornea should be observed during sleep. In case the eye remains open, boiled squeezed wet pad and bandage should be applied for the night. This precaution is continued as long as necessary.

F i g u r e l O - - T h e upper and lower lids are tied with a stout nylon suture passing through the skin only.

passage through the tarsal plate, the lid is turned to make sure that there is no through-and-through passage. The suture is tied as a reef-knot, making sure that the first knot is not too tight, or else it will cheese wire through; just enough force is applied to keep the suture in place so that healing and fusion of the tissues takes over. The site of tarsal plate entry depends upon the degree of ptosis. In lower degrees of ptosis, the suture is passed close to the upper edge of the tarsal plate. In severe ptosis the fixation is done away from the posterior edge, over the anterior surface of the tarsal plate. However, it should not be placed more than 5 nun from the posterior edge of the tarsal plate, else there shall be problems closing the eye and also a strong tendency to entropion and trichiasis. Usually, the first suture is tied followed by the sutures on the side (Fig. 9). The eyelid is allowed to fall back to its normal position. No conjunctival sutures are applied. In that sense, it becomes a no-suture ptosis surgery technique.

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P O S T O P E R A T I V E P R O B L E M S

O v e r - C o r r e c t i o n

With overcorrection, there is difficulty in closing the eye: If excessive plication is performed or the fixation of the levator is performed too anteriorly, the patient experiences great difficulty in closing the eye. The lid margin is seen to compress the eyeball and moves over the cornea with a good deal of friction. The lid margin also shows certain amounts of entropion; even the cilia might rub the cornea. Since we started tying the lids at the end of surgery, this problem is nearly abolished. Before waiting until the con- clusion to tie the lids, we saw two cases of corneal abra- sion for which bandage lenses were successfully used. The initial edema after surgery, even if not excessive, con- tributes to the problem. Most cases settle down with con- servative treatment. Once in a while, especially when the surgeon is not experienced with this technique, it may be necessary to reoperate very early. The re-operation is done under general anesthesia. The levator muscle is detached by cutting the steel suture. It is then reattached closer to the upper edge of the tarsal place. The strong compressive forces on the eyeball and the entropion go

away immediately. There are occasional cases when a decision for re-operation is difficult because the problem does not seem threatening. In these cases, a bandage con- tact lens is applied. If things improve within 1 week, as they usually do, the contact lens removed. A contact lens also gives a breathing space for the surgeon to think over the need for loosening the levator as described above.

action to manage over-correction. The parents should be advised to watch the behavior of the child's operated eye during sleep. If there is exposure of more than one- fourth of the cornea, it should be lubricated with antibi- otic ointment or closed with a surgical tape. Since there is no lagophthalmos following this operation, there is no risk of a corneal ulceration developing.

Under-Correction In the early postoperative period, under-correction has many possible reasons. The levator muscle may have been misidentified and another structure may have been fixed to the tarsal plate. The levator muscle may be poorly devel- oped hence devoid of lifting power. Another reason could be cheese-wiring of the tarsal plate due to tight suturing. In such a failed case, it is reasonable to re-explore the sur-

gical area and correct any mistake that is detected. We have been twice gratified by the good results following such an approach. If the lid tissues are less pliable that may prevent double evertion of the lid during surgery, it is better to wait for several weeks and months, and, lid plia- bility permitting, do the re-operation. In case that is not possible, an alternate procedure is performed. We prefer to perform "plication of the orbicularis oculi muscle."

Peaking or Notching of the Eyelid Peaking or notching can occur if the levator fixating sutures are not applied in harmony. Notching becomes apparent during surgery and should be corrected imme-

diately. "Hoping for the best" is a bad policy and results in poor results. Once it develops, re-operation to loosen the defect suture is undertaken to correct the defect.

Lid Lag In slight ptosis, moderate and a large number of severe ptosis, there is no lid lag and the lid moves in harmony with the other side. However, there are many cases that are operated for severe ptosis, who show significant lid lag.

Lagophthalmos No lagophthalmos has been noticed in our patients who underwent conjunctival route sutureless plication of the levator muscle.

Corneal Ulcer In the early postoperative, a corneal abrasion is to be prevented by proper closure of the lids and by early

Regression Some patients develop regression with time. It usually is slight, but may sometimes be sufficient to raise the con- cern of the patient or the parents. We prefer to wait for at least one year before doing an alternate operation, our favorite being orbicularis oculi plication. An occasional patient of severe ptosis shows a disappointing, gradually increasing regression leading to a total failure. It is diffi- cult to define the cause of this total failure, but the possi- bilities are suture failure or a degenerated fibrotic levator palpeberal superioris (LPS). It is best not to re-explore, but to go straight for an alternate ptosis procedure.

DISCUSSION The greatest influence on ptosis surgery was produced in the early twenties by Blaskovics (I). He did levator ten- don shortening via conjunctival approach, at the same time by resecting the upper portion of the tarsus. Most of the conjunctival route ptosis procedures used today are offshoots of the original Blaskovics.

There are wel l -known modif ica t ions by Agaston (1942) (3), Berke (1952) (2), and Iliff (1954) (4). Agas- ton reached the levator muscle through the tarsal plate. He used the pretarsal space as an important landmark. Berke applied sutures differently than Blaskovics (2). Iliff excised levator tendon as well as the conjunctiva (4). All the techniques have a few things in common: excess ive dissect ion, sacr i f ice of t issues and some

severe postoperative complications. As a consequence, it is difficult if not impossible to enhance or undo the result of the original surgery.

The technique described herein is a totally new way of tackling the levator muscle in order to correct ptosis. Each step of the operation is clearly defined and worthy of meticulous execution. The biggest problem during surgery is bleeding, which can obscure the surgical field; this happens especially when manual means of cutting and dissection are employed. At every stage, one needs to stop the bleeders either by pressure or by cautery. With the Fugo Blade, bleeding is less of a problem. Low energy settings are used. The Fugo Blade is moved slowly over the tissues with a quick movement which

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J l l l Figure 11--(A) Unilateral congenital ptosis in a 4-year-old child. (B) The result 1 5 days after levator plication. The eye had very little lid lag, but no lagophthalmos.

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Figure 12--(A) Severe congenital ptosis in an adult. (B) The same patient 1 5 days after surgery. No lid fold has developed as of yet.

may cause tearing of a larger blood vessel, which conse-

quently bleeds. However, by touching the bleeding spot

with the Fugo Blade, the bleeding stops immediately without charring. This happens by virtue of two proper-

ties of the Fugo Blade: the ablation of the tissue and the

immense oscillation of the tissue particles caused by

Fugo blade that plug the small blood vessels. The Fugo Blade is immensely useful for clearing the tissues ante-

rior to the tarsal plate. These tissues are in layers and are

well stretched; they also have many blood vessels in

them. The tissues just disappear as they are ablated in front of the activated advancing tip of the Fugo Blade.

Alternately, the tarsal plate can be exposed manually

plus bipolar cautery at the cost of some tissue trauma

and charring. Overall, tissue trauma in the conduct of the operation is quite low.

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The choice of sutures and the mode of closure of the surgical site need some explanation. Our choice of 80-g vanadium steel sutures is based on our experience start- ing 1979. We have used a 40-g version for suturing the corneo-scleral incisions in tens of thousands of cataract cases which has given us some insight in to the advan- tages of this material. Atraumatic sutures can be made at a very low cost by using 32-gauge disposable nee- dles, suitably bent, steel threaded and pinched with dental pliers. Such sutures can be sterilized by autoclav- ing or by flash sterilization. There is no tissue drag during application. Once in place, they cause zero tis- sue reaction. They need never be removed. However, there is one concern regarding what will happen if a patient with steel sutures undergoes magnetic resonance imaging scan for some reason. We believe that nothing shall happen.

Figure 13--(A) A 14-year-old oatient with severe congenital unilateral ptosis.

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Figure 14--(A) 1 3-year-old patient with severe congenital ptosis.

Figure 13--(B) The same patient three months after surgery. The lid fold that has developed does not exactly match the other eye. However the result is passable.

Figure 14--(B) The same patient 3 months later. He had developed entropion and trichiasis in the early postoperative period for which a bandage lens was applied. The lid gained normalcy in about 2 weeks after the lens was removed.

Marcus Gunn Ptosis We do not advocate the sacrifice of LPS muscle on both sides fo l lowed by bilateral brow suspension (Beard 1982). Instead we make use of the available healthy lev- ator muscle of the ptotic lid. When the ptosis gets cor- rected, the range of lid movement connected to jaw winking gets correspondingly reduced or even becomes imperceptible.

Creation of a Lid Fold We make no part icular effor t to surgical ly create a lid fold. The mere correction of the ptosis may create a pleasant fold on its own. We present some results. The still pictures do tell the story, but the results are

mos t c o n v i n c i n g when the v ideos are e x a m i n e d (Figs. l l -14).

Beard (1981) stated, "All told, there are well over a hundred operations and variations of operations for pro- sis have been reported. This is good evidence that the "ideal" operation has not as yet been devised and proba- bly never shall be. Our present concepts may seem archaic in the not too distant future."

Our goal has been to develop a ptosis surgery tech- nique that: 1) Involves minimum tissue handling. 2) Min imum sacrifice of tissues. 3) May be redone to reduce or enhance the correction. 4) Does not compro- mise the ocular tissues for re-surgery by any other

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currently used surgical technique. 5) Applicable to all grades of ptosis. 6) Easy to learn.

Our experience on 80 patients in the past two years has shown that all the points mentioned above are more or less achieved by the technique. Hence, we believe that this new concept of "sutureless plication of levator muscle" is a step forward towards the realization of an ideal ptosis procedure.

REFERENCES

1. Blaskovics L. A new operation for ptosis with shortening of the lev ator and tarsus. Arch Ophthahnol 1923;52:563.

2. Agatson SA. Resection of levator palpebrae muscle by the conjunc- rival route for ptosis. Arch Ophthalmol 1942 27,994.

3. Berke RN. A simphfied Blaskovics operation for blephm'optosis. Arch Ophthalmol 1954;48:460.

4. Iliff CE. A simplified ptosis operation. Am J Ophthalmol 1954; 37:529.

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