The complications of ptosis surgery include undercorrection, poor Hd crease, overcorrection, peaked Hd, corneal staining, ectropion, entropion, and loss of lashes.
Undercorrection is a complication encountered more frequently in surgery for congenital ptosis. It occurs when not enough aponeurosis and levator are resected; when tight horns of Whitnall's check ligaments are not recognized as limiting the muscle action and are not cut; or when all the tissues are so abnormal thatonly partial correction can be obtained. The patient and the patient's family must understand that the surgeon cannot remake completely what has been a failure in development. In some cases, it is impossible to achieve a perfect result. When an undercorrection does occur and the patient and surgeon feel that further surgery is indicated, the amount of motion should be reevaluated and surgery planned accordingly. If a failure occurs with a conjunctival approach, it is better to repeat the surgery through the skin incision. Less bleeding will be encountered, and the aponeurosis is more easily identified. Conversely, a conjunctival approach can be used to advantage if a skin approach has produced a failure. The surgeon should feel at home in either type of surgery, and tailor his work accordingly.
Poor Lid Crease
A poor lid crease postoperatively can be corrected by making an incision through the skin where the lid fold should be.
Since methylene blue or other marking inks smear and become indistinct when the lid is put on stretch, we routinely mark the lid crease with a light incision. If a crease is indistinct, the lid edge is pushed upward a number of times with a cotton swab to produce a natural crease in the skin. With the lid pushed up, a No. 15 BardParker knife is passed very lightly across the lid in the crease to mark the skin. This cut will remain when the lid is put on stretch and will indicate where the incision is to be made to make a lid crease or for the anterior approach for levator shortening.
A 4-0 black silk suture is placed in the gray line and tied to the knurled knob on the lid plate to put the lid on mild stretch. The skin is incised along the marked crease with sharp-pointed iris scissors. Bleeding is controlled with cautery. The incision is carried down through the orbicularis to the orbital septum. If the skin is redundant, an elliptical section can be removed with scissors. A 7-0 chromic catgut suture is used to invaginate the skin edges and fasten them to the orbital septum to make a lid crease. The needle is passed through the orbital septum and levator aponeurosis, taking a small bite of tissue, and then passed through the upper skin edge and the lower skin edge. A tie is made deep in the incision, the knot being completely buried. Occasionally at the time of surgery, the lid crease does not seem to extend as far nasally or temporally as desirable, and this method is used to extend it. This has proven most effective in our hands and has been better than through-and-through lid sutures. A lid closure suture and tape to the brow is used for 24 hours.
Overcorrection in congenital ptosis is unusual but does occur if a suture is inadvertently placed through Whitnall's ligament during a resection of the aponeurosis, fastening the lid to the firm fascia of the brow. Correction requires taking the wound down and cutting the offending suture.
Overcorrection, if it is very slight, should be treated with massage for two to three months. If slight overcorrection remains, Berke's tarso-aponeurosis tenotomy through the tarsal plate gives good results. It consists of everting the lid on a Desmarres retractor, and making an incision through the tarsus approximately 2 mm from the retrotarsal margin, through conjunctiva, tarsus, levator aponeurosis, and orbital septum, leaving only the skin. This incision is across the whole tarsus. An inverted Frost suture from the upper lid to the lower lid is used, and the suture is taped to the cheek to apply mild traction downward for 8 to 10 days. Although minor overcorrection can be reversed this way, there may be considerable discomfort and occasional tissue reaction from the Frost suture, and, therefore, the suture may have to be removed sooner.
Insertion of Fascia into Aponeurosis
General anesthesia should be used, as local anesthesia distorts the tissues and makes the dissection difficult. The anterior approach is made as previously described - through the lid fold, the orbicularis, and orbital septum. These are retracted upward with a Desmarres retractor, and the levator tendon and muscle are isolated.
A piece of preserved fascia two times the amount of overcorrection plus 2 mm, assuming 1 mm will be caught in the suture line at each end of the anasatomosis. For example, if the lid is 2 mm too high, a 6-mm piece of fascia (2 x 2 + 2) will be needed to drop the Hd to the desired position.
Suturing to each end of the lengthened muscle is done by a mattress stitch with 6-0 chromic catgut. The orbital septum is not resutured, but the skin is closed with closely spaced 8-0 black silk sutures. Decadron is injected beneath the suture line, and a firm pressure bandage is applied. The eye is kept bandaged with mild pressure for one week.
Grafts of sclera at the upper edge of the tarsus, either buried under the conjunctiva or left bare, have not given us as consistently good results as the grafts at the tendon-muscle junction. However, if overcorrection is markedly nasal or temporal, attention has to be directed to this particular area, especially if the exact course of the previous surgery is not known. In this case, the sclera is inserted either temporally or nasally beneath the conjunctiva at the upper edge of the tarsus.
After A Frontalis Sling: If at the time of surgery one arm of the sling is too tight, it will produce a peaking of the lid, which usually can be relieved by grasping the lid margin at the site of the peak by Adson forceps, and pulling with a see-saw motion to reset the arms of the rhomboid. If this maneuver is not sufficient, the knot of the sling has to be undone and the sling loosened. If the peak occurs postoperatively, the offending arm of the sling must be cut and the surrounding fibrous tunnel excised over a long enough area to release the lid margin for a proper curve. An inverted Frost suture fastened to the cheek with adhesive is then used for five to six days to hold the lid margin in an overcorrected position during early healing period.
After a levator shortening procedure, peaking may result from excision of too much tarsus, thus interfering with the skeleton of the lid, or from uneven tension on the sutures between the shortened aponeurosis and the tarsus. Correction can usually be accomplished by Berke's suggested procedure for overcorrection of ptosis. The traction suture is placed at the site of the peak.
Corneal staining is frequently noted for the first few weeks and, in children, seems to cause little or no problem as the epithelium soon heals. In some adults, however, the staining may persist, and a recheck for a possible dry eye syndrome is indicated. If this is found, a temporary occlusion of the puncta is done. If, however, there are sufficient tears, ointment and closure of the lids with clear tape should be used at night; in most instances, after a few weeks, the staining will disappear. It is conceivable that with the lid in the normal position, the cornea would not be able to tolerate the extra exposure. In such a case, a soft contact lens should be tried. If that fails to relieve the symptoms, the lid will have to be let down to its former position. This is an extremely rare occurrence.
With the frontalis sling procedure, infection along the fascial tracts may be a complication. This could result from contamination of the fascia from the skin or from inadvertent pulling of cilia into the tract at the time the fascia is threaded. Irrigation of the tract with gentamycin has been helpful in avoiding such a problem.
If the ends of the fascia are not properly buried, they will produce what appears to be a pustule at the site of the incision. This opens and, in most instances, is a sterile abscess probably produced by the mass of foreign tissue at the site of a fascia tie and catgut knot. Since we began using a single tie rather than a square knot of fascia, such complications have been fewer. However, it is important that the tie and the ends of the fascia be deeply buried in the tissues of the brow, which is extremely vascular and usually can accept this amount of foreign tissue. Late infections of the frontalis sling operation, when tissues other than fascia are used, are common, and usually it is necessary to remove the foreign material before the infection can be controlled. This does not necessarily jeopardize the operative success, as by this time there is usually enough fibrous tissue along the tract to support the lid.
On occasion, 10 to 14 days after surgery, swelling and redness may develop in reaction to catgut. This should not be confused with infection. Local steroids can help treat such cases. Operative infection usually appears within two to four days and should be actively treated with antibiotics.
Ectropion is a rare complication of the frontalis sling or levator shortening procedure, and is usually manifest by an upward and outward turning of the lashes rather than involvement of the whole lid. It can be treated by making an incision through the skin at the lid fold and cutting away the subcutaneous scar tissue that is turning the lash follicles upward. The skin is undermined upward for 1 cm and then refastened with 8-0 black silk. This merely relaxes the tension on the cilia follicles.
This should be distinguished from the slight downward turning of the cilia that occurs when the levator aponeurosis is refastened to the upper edge of the tarsus rather than to its normal insertion along the anterior one third of the tarsus. To correct this, the skin is opened along the lid fold. Dissection is carried upward for 1 cm and downward to the cilia base. Partial excision of the pretarsal muscle is done, and interrupted 7-0 chromic catgut sutures are used to put tension on the cilia base to point the cilia upward and outward. The skin is closed with 8-0 silk.
A true entropion may occur if the tarsal plate has been removed at the time of surgery, so that there is no skeleton remaining to the lid and the pull of the levator turns the lash margin in. When this occurs, a complete rebuilding of the lid is necessary, and usually some of the skin and subcutaneous tissue must be resected. Such a complication has not occurred in our practice with any of the procedures that have been described in this section for the treatment of ptosis.
Loss of Lashes
This is indeed a rare occurrence with present ptosis methods. It occurs when the patient has a marked infection along the lash margin or sutures have been placed improperly and pulled too tightly. Grafted lashes from the brow can be done but a good cosmetic result with paste-on lashes is often more acceptable to the patient.