Dr.Jyoti Dhaka, J20815, Dr. Sat Paul Garg, Dr.Ashutosh Kumar Singh, Dr.Ashok Kumar Grover
Management options of severe unilateral congenital ptosis:
Management of severe ptosis is controversial with varied opinion regarding its management. Maximal levator resection, anterior levator resection, whitnall’s sling, bilateral frontalis sling with no levator excision, bilateral frontalis sling with contralateral levator excision, unilateral frontalis sling are the various approaches described for severe unilateral congenital ptosis with poor levator function. Fridenwald and Guyton20 were the first to describe the frontalis suspension and since then it has involved in to standard surgical procedure for severe ptosis with poor levator action. Fox and Crawford have described two different ways of passing the sling material through the frontalis muscle. Lid contour assessment was traditionally carried out subjectively. We have used software Adobe Photoshop CS6 for contour measurement. We would like to emphasize the clinical applicability and simplicity of the methodology we have used in this study.Material and methods:
A prospective comparative study was carried out in thirty patients of severe congenital unilateral ptosis or jaw winking ptosis presenting in Vision Eye Centre, New Delhi during the period of July 2017 to June 2018. 30 patients were divided in to 2 groups, group 1 included 15 patients of severe unilateral congenital ptosis who underwent unilateral silicone sling frontalis suspension surgery and jaw winking ptosis who underwent ipsilateral levator excision with unilateral silicone sling frontalis suspension surgery and group 2 included 15 patients of severe unilateral congenital ptosis who underwent contralateral levator excision with bilateral fascia lata frontalis sling and jaw winking ptosis who underwent bilateral levator excision with bilateral fascia lata sling frontalis suspension surgery. 30 controls with no lid abnormalities were also studied.
Pre operative evaluation of ptosis was documented in terms of MRD1, vertical palpebral height, amount of levator function, margin crease distance, association with jaw movement. Post operatively MRD1, symmetry of lid height, lid crease, lid contour, presence of residual synkinesis, undercorrection were recorded.
Digital images were used for eyelid contour evaluation and analysis. All the images were processed using Photoshop version CS 6. Photographs were obtained at a distance of 1 meter from the subject using 18 megapixel digital Canon EOS 700 D camera with inbuilt flash. Multiple radial lines were drawn with the help of software at every 15 degree interval from the center of the pupil across temporal and nasal field of palpebral aperture. Shape of the eyelid contour in all patients was analyzed by measuring multiple mid pupil distances. Eyelid contour was expressed as the ratio between the sum of the temporal (165, 150, 135, 120, and 105 degree) and medial (15, 30, 45, 60 and 75 degree) radial lines. Lid contour in age matched control (with no lid abnormality) was found to be between 1.05-1.15 (ratio of temporal/medial) so we consider:
T/M Ratio between 1.05-1.15 as good lid contour
T/M Ratio between 0.95-1.04 and 1.16-1.25 as fair lid contour
And T/M Ratio <0.95 and > 1.25 as poor lid contour.
Results:
In our study we have noted that the mean improvement of mean marginal reflex distance (MRD1) after surgery in group 2 patients who underwent bilateral fascia lata frontalis sling surgery was higher (4.9+0.89 mm) than the group 1 patients (3.9+1.18mm) who underwent unilateral silicone sling procedure. This difference was found to be statistically significant with p value of 0.0001.
Post operative symmetry of lids was noted to be better in the bilateral fascia lata group (93.3%) as compared to the unilateral silicone sling group (73.3%)
Good lid contour was noted among 12 patients (80%) in group 1 and in 26 eyelids of 15 patients (86.7%) in group 2 with p value of 0.429. Fair lid contour was noted in 2 patients (13.3%) in group 1 and in 2 eyelids (6.7%) in group 2 (p value 0.407). Poor lid contour was noted in 1 patient (6.7%) and in 2 eyelids (6.7%) in group 2.
In our study we have found that lid crease was excellent in all 30 eyelids (100%) of patients who underwent fascia lata sling surgery while in silicone sling group it was found to be excellent in 12 patients (80%).
Discussion:
In our study better cosmetic outcome on the basis of lid contour was noted in bilateral fascia lata group patients (86.7%) as compared to unilateral silicone sling patients (80%).
The cosmetic outcome of ptosis surgery is also affected by the eyelid margin contour. Lid contour was measured subjectively in the past but we tried to quantify it with the help of software. Digital image analysis allows an objective assessment of the upper eyelid marginal contour after ptosis repair. Previously this software has been used for the quantification of eyelid contour in patients of Graves disease by Cruz et al and Sara F.T Ribeiro et al and Gherusa H. and Milbratz. No such comparative study to compare lid contour in bilateral fascia lata group and unilateral silicone sling has been done in the past. We are first time using this software for quantification of cosmetic outcome in post operative cases of ptosis.
Our study found that functional and cosmetic outcomes regarding MRD1, symmetry of lid height, lid crease and lid contour results were noted better in group 2 patients who underwent bilateral fascia lata frontalis sling as compared to group 1 patients who underwent unilateral silicone sling.
References:
- Beard C. A new treatment for severe unilateral congenital ptosis and for ptosis with jaw winking. Am J Ophthalmology. 1965;59:252-258.
- Yoon JS, Lee SY. Long-term functional and cosmetic outcomes after frontalis suspension using autogenous fascia lata for pediatric congenital ptosis. Ophthalmology. 2009 Jul;116(7):1405-14.
- Cruz AA, Coelho RP, Baccega A, Lucchezi MC, Souza AD, Ruiz EE. Digital image processing measurement of the upper eyelid contour in Graves disease and congenital blepharoptosis. Ophthalmology. 1998 May;105(5):913-8.
- Milbratz GH, Garcia DM, Guimarães FC, Cruz AA. Multiple radial midpupil lid distances: a simple method for lid contour analysis. Ophthalmology. 2012 Mar;119(3):625-8.
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