Hyperguides

Ophthalmology / Oculoplastics

Complications of Ptosis Surgery

Yoon-Duck Kim, MD, PhD
Article

Yoon-Duck Kim, MD, PhD

Introduction

Ptosis is one of the most common disorders encountered in ophthalmic plastic surgery. A thorough history taking and physical examination of a patient with ptosis provide the guidelines for making an appropriate choice in management. The appropriate surgical technique is usually determined by the amount of ptosis and levator function. Despite the application of a proper surgical technique for correction of the ptosis, a surgeon may encounter undesirable postoperative complications.

Complications of Fasanella-Servat Procedure or Putterman Procedure

Overcorrection

Overcorrection in the Fasanella-Servat procedure or Putterman procedure occurs from resection of too much tissue in the posterior lamella. This complication is rare because these procedures usually result in only 2 mm of elevation.1-3 Overcorrection can be corrected by downward massage of the upper lid or surgical suture adjustment within the first postoperative week.

Undercorrection

Undercorrection following a Fasanella-Servat procedure or a Putterman procedure can be caused by a number of factors. Undercorrection occurs when the procedure is improperly selected, such as when levator function is poor or when the ptosis is greater than 2 mm.1-3 Undercorrection also occurs when an insufficient amount of posterior lamella is resected. Finally, if the upper lid is everted in the first 2 weeks, a wound dehiscence may occur. The Fasanella-Servat procedure should never be repeated because too much tarsus would be sacrificed, affecting the stability of the upper lid. The management of undercorrection requires a levator resection or, if a levator dehiscence occurs, repair of the aponeurotic defect (Slide 1A, Slide 1B, Slide 1C).1,4



Peaked lid arch

In the Fasanella-Servat procedure, this complication results from incorrect placement of the hemostats. If too much tarsus is resected centrally, a central peaking occurs; if too little tarsus is resected centrally, the contour is too flat. If central peaking is noted, sutures can be placed only in the medial and lateral tarsus to raise those segments of the lid margin. If central flattening is noted, excess tarsus centrally should be excised and the wound sutured normally

If the contour deformity is noted postoperatively, it is usually managed with appropriate suture removal and/or revision of the tarsus within the first week as soon as upper lid edema has resolved.

Keratitis

Keratitis can be caused by suture, granuloma, or dry eye. Suture keratitis can be avoided using subconjunctival placement of a rapidly absorbable chromic gut 6-0 suture.2,3 If a corneal abrasion occurs, it should be treated with removal of the exposed sutures, use of ophthalmic ointment, a collagen shield, or a therapeutic soft contact lens.1,4

Pyogenic granulomas are rare but can develop 3 to 6 weeks postoperatively. They are easily removed under topical anesthesia. Postoperative keratitis sicca can be induced by reducing the conjunctival basic secretors.

Complications of Levator Surgery

Overcorrection

Overcorrection in congenital ptosis is rare but may occur, particularly if levator function is poor. A small overcorrection in a patient with poor levator function should be followed because the lid usually drops in 1 month postoperatively. Overcorrection may occur in patients with congenital or acquired ptosis with good or moderate levator function.

Treatment with ocular lubricant is indicated for the exposure keratitis. Massaging and pulling down the upper lid is helpful in the early postoperative period. If a drop in the upper lid is not expected and the overcorrection is causing a functional or cosmetic problem, the eyelid can be lowered by Berke levator tenotomy,1 levator recession4 (Slide 2A, Slide 2B, Slide 2C), or levator recession with a spacer.5

Undercorrection

Undercorrections are more common than overcorrections.6 Following a levator resection, undercorrection can occur for a number of reasons, including improper choice of operation, inadequate resection of the levator due to inaccurate preoperative measurements, premature dissolution of absorbable sutures, and large postoperative hematomas. Non-absorbable sutures are preferred to absorbable sutures in suturing the levator to the tarsus.1

In patients with good levator function, further resection of the levator can be performed (Slide 3A, Slide 3B, Slide 3C). However, in patients with poor levator function, frontalis suspension should be considered. Residual segmental ptosis is best managed by a full thickness eyelid resection procedure.

Poor eyelid contour

Poor eyelid contour is caused by uneven placement of the sutures that attach the levator to the tarsus. To ensure a satisfactory eyelid contour, it is better to place three sutures approximately 2 mm to 3 mm below the superior tarsal border and one suture at the midpupillary line and the others 3 mm to 4 mm apart medially and laterally. The poor eyelid contour may be divided into nasal notching, central peaking, and temporal notching.

To repair the eyelid contour in the early postoperative period, the surgeon could replace the sutures in the correct position. However, if revision is performed later, the levator must be dissected from the tarsus again and repositioned in the appropriate location.

Eyelid lag, lagophthalmos, keratitis

Eyelid lag and lagophthalmos are to be expected after large levator resection and are, therefore, side effects rather than complications. Intractable lagophthalmos can occur when the septum is inadvertently sutured. If these complications develop, medical management should include topical lubricants and taping of the eyelid. If severe symptoms and corneal problems persist, surgical corrections such as temporary tarsorrhaphy, levator recession, and a levator tenotomy are warranted.1,4,5
SLIDE 4

Entropion, ectropion1

Entropion can occur following large or maximum resection resulting in shortening the posterior lamella of the eyelid with regard to its anterior lamella (Slide 4). If entropion occurs, the initial management consists of observation and massage. However, the following surgical procedure is indicated when the entropion does not resolve:
  1. Excise a small segment of skin above the previous incision line and undermine the skin down toward the eyelash follicles.
  2. Pull the skin superiorly and fixate it to the tarsus.
  3. Close the skin.

An upper eyelid ectropion can occur after a large or maximum levator resection by the skin approach when the skin incision is too low and the crease is fixated too high. The following are the surgical procedures used if an upper eyelid ectropion occurs:

  1. After making an eyelid crease incision, undermine the skin inferiorly.
  2. Fixate the skin at a lower level on the tarsus.

Eyelid crease deformity

In managing upper lid crease abnormalities, symmetry is important. If the upper lid crease is absent, it can be formed by fixing the wound edges to the levator or tarsus at the proper level. Elevating a low lid crease is easier and produces a better result than lowering a crease that is too high.
SLIDE 5A

Conjunctival prolapse7

Conjunctival prolapse occurs secondary to large, maximum levator resections when the suspensory ligament between the conjunctival fornix and levator-superior rectus complex is severed. However, it may be prevented by anchoring redundant conjuctiva to the levator with two or three well-placed mattress sutures or excising a 5-mm to 6-mm ellipse and then suturing the edges together with a fine absorbable suture.
SLIDE 5B

If conjunctival prolapse occurs, topical steroid-antibiotics eye drops should be instilled for 2 to 3 weeks. If no resolution appears, simple excision and placement of two or three double-armed mattress sutures through the full thickness of the eyelid can be performed (Slide 5A, Slide 5B).

Loss of eyelashes

Loss of eyelashes is due to dissection and/or cautery within 2 mm of the lid margin, resulting in damage to the cilia follicles. Treatment includes blepharopigmentation or artificial lashes. If the area of madarosis is smaller than 8 mm, surgical wedge resection is helpful.

Complications of Frontalis Suspension

Overcorrection

Overcorrection with frontalis suspension is rare in congenital ptosis with a poor levator function.

If an overcorrected sling is revised within the early postoperative period, the brow incisions can be opened, the fascia lata knots untied, and the upper lid adjusted to the appropriate level. If the revision is performed later, the surgeon must open the upper lid crease incision and recess the fascia lata from the tarsus (Slide 6A, Slide 6B).1,4



Undercorrection1,8

An immediate postoperative undercorrection usually results from slippage of the fascial knot. When slippage occurs within the first 2 weeks, the surgeon must open the brow incision and retie the fascia. It is important that the fascia be tied with firm tension at the time of the procedure. It is not uncommon that undercorrection of ptosis occurs after an initial successful result, and it can be corrected with a resling with fresh fascia strips (Slide 7A, Slide 7B).


Infection1,4,5

Infection following frontalis suspension is rare and can be prevented by parenteral antibiotics, starting the day before surgery and continuing for at least one week postoperatively. Some small incisional abscesses occasionally develop above the eyebrow (Slide 8A, Slide 8B, Slide 8C). If the abscesses do not resolve with hot compresses or drain spontaneously, they can be pricked and opened with a needle.



Poor eyelid contour

A contour deformity is due to either incorrect placement of the sling or if the sling is sutured to the tarsus, improper placement of the sutures in the tarsus.1 If the contour deformity is first recognized postoperatively, revision of the sling should be done.
SLIDE 9

Lagophthalmos, keratitis (Slide 9)

Lagophthalmos is an expected side effect of the frontalis suspension. Medical management should include topical lubricants and nightly taping of the eyelid. For the patients with poor Bell’s phenomenon, frontalis suspension with a silicone rod could decrease the chance of severe exposure keratitis because of the elastic nature of the silicone rod.9

Conclusion

A thorough knowledge of eyelid anatomy, comprehensive evaluation, and appropriate surgical procedure are essential in managing blepharoptosis patients. Even a well-planned and well-performed procedure can have undesirable side effects or complications. A comprehensive knowledge and proper management of these complications of ptosis surgery are mandatory to an oculoplastic surgeon.

References

  1. Callahan MA, Beard C. Beard’s Ptosis. 4th ed. Birmingham, AL: Aesculapius; 1990;113-167.
  2. Carroll RP. Preventable problems following the Fasanella-Servat procedure. Ophthalmic Surg. 1980;11:44-51.
  3. Putterman AM, Fett DR. Müller’s muscle in the treatment of upper eyelid ptosis: A ten-year study. Ophthalmic Surg. 1986;17:354-360.
  4. Dortzbach RK. Ophthalmic Plastic Surgery: Prevention and Management of Complications. New York: Raven Press; 1994:65-90.
  5. Crawford JS. Congenital blepharoptosis. In: Smith BC, Della Rocca RC, Nesi FA, Lisman RD, eds. Ophthalmic Plastic and Reconstructive Surgery. Vol 1. St. Louis, MO: CV Mosby; 1987:631-653.
  6. Berlin AJ, Vestal KP. Levator aponeurosis surgery: A retrospective review. Ophthalmology. 1989;96:1033-1036.
  7. Buckman G, Levine MR. Treatment of prolapsed conjunctiva. Ophthal Plast Reconstr Surg. 1986;2:33-39.
  8. Crawford JS. Repair of ptosis using frontalis muscle and fascia lata: A 20-year review. Ophthalmic Surg. 1977;8:31-40.
  9. Leone CR Jr, Shore JW, Van Gemert JW. Silicone rod frontalis sling for the correction of blepharoptosis. Ophthalmic Surg. 1981;12:881-887.