Müller's Muscle-conjunctival Resection Combined With Tarsectomy for Treatment of Congenital Ptosis

Müller muscle-Conjunctival Resection (MMCR) Surgery: A Comprehensive Literature Review

PURPOSE

This literature review aims to provide a comprehensive overview of the current understanding, indications, techniques, outcomes, and complications of Müller muscle-conjunctival resection (MMCR) surgery. It also addresses areas of debate with MMCR such as predictability concerning Phenylephrine response as well as the amount of muscle resection required.

METHOD

This literature review was compiled based on the available evidence from PubMed from 1975 to August 2023.

RESULTS

The success rate of MMCR ranges from 72% to 95%, with high patient satisfaction reported in most studies. The exact range of eyelid elevation after MMCR is variable, with a reported average of 2.1 mm MRD1 elevation.

CONCLUSION

MMCR is a well-established surgical technique used to correct upper eyelid ptosis that results from dysfunction or attenuation of the levator aponeurosis. MMCR proved to be a safe and effective procedure with a high patient satisfaction rate and low risk of complications.

Orbital septum attachment site on the levator aponeurosis sling for mild congenital blepharoptosis

PURPOSE

This study aimed to investigate the value of the orbital septum attachment site on the levator aponeurosis (OSASLA) sling in correcting mild congenital blepharoptosis.

METHODS

A total of 60 patients (92 eyes) with mild congenital blepharoptosis (levator function ≥ 8 mm) were treated in our hospital from January to October 2021, and relevant data of these patients were collected. All patients underwent OSASLA sling for ptosis correction. The distances from the superior tarsal border to the OSASLA were measured. The primary outcome was the number of postoperative changes in the marginal reflex distance 1 (MRD1). Pearson's correlation coefficient between the distance from the superior tarsal border to the OSASLA and the height of the upper eyelid elevated was analyzed.

RESULTS

Fifty-eight patients (89 eyes) successfully underwent OSASLA sling surgery. The preoperative MRD1 was 1.4-3.6 mm (mean 2.1 ± 0.5 mm), and the postoperative MRD1 was 3.4-5.0 mm (mean 3.7 ± 0.6 mm). The distance from the superior tarsal border to the OSASLA sling was significantly and positively correlated with the height of the upper eyelid elevation (r = 0.7328, P < 0.0001). The eyelid margin positions of the patients did not regress substantially during 6-18 months of follow-up.

CONCLUSIONS

Compared with the shortening of levator palpebrae superioris (LPS) and pleating of LPS, the OSASLA sling is a less invasive, more effective, and easy-operating surgery for mild congenital blepharoptosis.

Predictability of the Phenylephrine Test in Congenital Ptosis: Ten Years of Experience

PURPOSE

To assess the predictability of phenylephrine testing for congenital ptosis and review outcomes of Müller's Muscle-conjunctival resection (MMCR) for congenital ptosis across ten years of follow-up.

METHODS

In this retrospective case series, all patients who underwent MMCR for congenital ptosis at a single institution between 2010 and 2020 were identified. Exclusion criteria included patients who had not undergone preoperative testing with 2.5% phenylephrine in the superior fornix; patients who underwent revision surgery; and patients who had a broken suture in the early postoperative period. Demographics, margin-reflex distance 1 (MRD1) values pre- and postphenylephrine, millimeters of tissue resected intraoperatively, and final postoperative MRD1 were recorded.

RESULTS

A total of 28 patients were included; 19 patients received MMCR and 9 patients received a combined MMCR plus tarsectomy. The amount of tissue resected ranged from 5 to 11 mm. There was no significant difference between median postphenylephrine MRD1 and median final postoperative MRD1 in either surgical group. Neither patient age nor levator function was significantly associated with a change in MRD1 in either group. The addition of a tarsectomy had no bearing on the final MRD1 value.

CONCLUSIONS

MMCR is a viable option for patients with congenital ptosis and moderate levator function with a response to phenylephrine. In these patients, MRD1 after 2.5% phenylephrine testing correlates to the final postoperative MRD1 outcome within 0.5 mm.

Conjunctival Müllerectomy With or Without Tarsectomy Using Absorbable Versus Nonabsorbable Suture

PURPOSE

To compare the outcomes of blepharoptosis repair using conjunctival Müllerectomy with or without tarsectomy (CM±T) using absorbable suture versus nonabsorbable suture.

METHODS

Retrospective case-series of all consecutive cases of CM±T ptosis repair between January 1, 2019, and August 31, 2021. Patients were placed in groups based on whether they had absorbable or nonabsorbable suture used during their procedure. Preoperative and postoperative measurements of MRD1 were gathered in both groups, and information on patient satisfaction, symmetry, complications, and reoperations.

RESULTS

Ninety-two patients had surgery using nonabsorbable suture and 96 patients had surgery using absorbable suture, with average age of 72.0 and 70.9 years, respectively ( p = 0.488). When comparing nonabsorbable to absorbable suture, the groups did not differ on average preoperative MRD1 (1.11 mm [±0.96] vs. 0.96 mm [±0.86]; p = 0.161), average postoperative MRD1 (3.18 mm [±0.54] vs. 3.20 mm (±0.51); p = 0.736) or average MRD1 improvement (2.09 mm (±0.86) vs. 2.25 mm (±0.79); p = 0.089). Goal MRD1 was achieved in 85.3% of nonabsorbable cases and 82.8% of absorbable cases ( p = 0.562) and the rate of reoperation between groups was not significant ( p = 0.63). Good postoperative symmetry was noted in 91.6% of nonabsorbable and 91.0% absorbable suture cases ( p = 0.83). No difference in the number of complications was noted between groups ( p = 0.88), including need for contact lens placement (2.7% nonabsorbable, 1.3% absorbable; p = 0.37).

CONCLUSIONS

The use of absorbable suture was found to have predictable and effective outcomes similar to cases using nonabsorbable suture for CM±T without an increase in complications or rate or reoperation.

Efficacy and Complications of External and Internal Pediatric Blepharoptosis Repair Techniques: A Systematic Review

PURPOSE

To review and evaluate the efficacy and complication rates of external and internal blepharoptosis repair techniques in pediatric patients.

METHODS

The systematic review protocol was published on PROSPERO (CRD42020197343). Embase, MEDLINE, CENTRAL, and ClinicalTrials.gov were searched without date limitations. Two independent reviewers evaluated the articles for inclusion. Study quality and risk of bias were assessed using GRADE and Cochrane's ROBINS-I tool, respectively.

RESULTS

Of 2,228 articles screened, 23 studies involving 730 patients were included. There were 20 case series and 3 retrospective cohort studies, but no randomized controlled studies. Overall study quality was low with serious risk of bias according to the GRADE and ROBINS-I criteria, respectively. External levator resection was the most studied procedure, evaluated in 18 studies. Seven studies investigated internal approaches including the Fasanella-Servat procedure. There was no standardized evaluation of surgical efficacy. Reoperation rates were 16.6% (range 3.6-50.9%) for external levator resection compared with 22.2% (range 0.0-25.8%) for internal approaches. The commonest postoperative complications were not sight-threatening. The most consistently reported complication was undercorrection, occurring at rates of 8.4% (range 2.4-16.7%) and 15.3% (range 2.7-75.0%) for external levator resection and internal approaches, respectively. There were no consistently applied, validated patient-reported outcomes or cosmetic outcomes.

CONCLUSIONS

External and internal approaches have been successfully employed in pediatric blepharoptosis repair. However, noncomparative designs and risk-of-bias limit existing studies. Thus, prospectively designed studies with standardized outcome measures are required to minimize reporting bias, facilitate evidence synthesis, and support clinical decision making.

Adjustable Ptosis Correction via Posterior Levator Advancement With Minimal Superior Tarsectomy

PURPOSE

To report the surgical technique and outcomes for adjustable ptosis correction using a posterior levator advancement with minimal superior tarsectomy.

METHODS

A retrospective single-center study was conducted on patients who underwent adjustable ptosis repair via posterior levator advancement with minimal superior tarsectomy by a single surgeon from 2002 to 2018. Patients with greater than 1 mm asymmetry between eyes or contour abnormalities underwent nonsurgical adjustment in the office within 6 days of surgery.

RESULTS

A total of 79 patients (146 eyelids) were included in this study. The patients were female (67%), underwent bilateral surgery (87%) with mean age of 63 years (range, 20-92). The mean improvement in marginal reflex distance 1 at postoperative month 1 was 2.56 ± 1.04 mm (p ≤ 0.0001). Postoperative symmetry of 1 mm or less between eyes was achieved in 96.6% of patients. Only 8 eyes (5.4%) underwent in-office adjustment postoperatively. No demographic or clinical differences were noted in eyes that required adjustments. Postoperative complications included dry eyes that resolved by 3 months (13.6%), suture cyst (1.4%), corneal abrasion (1.4%), and persistent eyelid edema (1.4%). Surgical revision was required in 2.8% of eyes.

CONCLUSIONS

The adjustable posterior levator advancement with minimal superior tarsectomy is an effective surgical technique for ptosis repair with the added benefit of in-office adjustability to correct minor asymmetries.

Efficacy and predictability of Muller's muscle-conjunctival resection with different tarsectomy lengths for unilateral blepharoptosis treatment

BACKGROUND

To investigate the efficacy and predictability of Muller's muscle-conjunctival resection (MMCR) with different lengths of tarsectomy for the treatment of unilateral mild-to-moderate blepharoptosis.

METHODS

A retrospective study of patients who underwent MMCR with tarsectomy for unilateral mild-to-moderate blepharoptosis between January 2016 and December 2019 was performed. Individuals with adequate photographic documentation and good levator function were included. Data on age, gender, surgical designs, pre-operative and post-operative marginal reflex distance 1 (MRD1) and tarsal platform show (TPS), and complications were retrieved.

RESULTS

Sixty patients underwent 8-mm MMCR with 1- or 2-mm tarsectomy; 53 patients (88.3%) showed postoperative symmetry of MRD1 within 1 mm. The average postoperative improvement in MRD1 was 2.15 ± 0.8 mm. Thirty-two patients received 8-mm MMCR with 1-mm tarsectomy (group 1), and 28 patients underwent 8-mm MMCR with 2-mm tarsectomy (group 2). In group 1, postoperative symmetry rate was 90.6%, and the mean elevation of MRD1 was 1.66 ± 0.6 mm. In group 2, postoperative symmetry rate was 85.7%, and the mean elevation of MRD1 was 2.72 ± 0.6 mm. Both groups showed postoperative symmetry of TPS and significant improvement in eyelid position (p < 0.0001). No postoperative complication was noted, and no secondary surgery was needed.

CONCLUSIONS

MMCR with tarsectomy was proven to be a safe, rapid, and effective method for patients with mild-to-moderate ptosis. Predictability and symmetry of the outcome were statistically confirmed. We further suggest a 2.1-mm expected MRD1 elevation as a cut point for choosing between 1- or 2-mm tarsectomy.