The purpose of this study was to demonstrate the suitability of local anesthesia in the pediatric age group for oculoplastic procedures. The authors present a case of frontalis sling surgery performed under local anesthesia in a 15-year-old boy with bilateral congenital ptosis. No significant technical difficulties were encountered during the procedure. Optimal intraoperative eyelid placement was facilitated by the patient’s comfort and cooperation. For some selected children, local anesthesia is a good alternative to general anesthesia to obtain the best outcome.
From Solihull Hospital, West Midlands, United Kingdom.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Jerald William, MBBS, MRCOphth, Solihull Hospital, Ophthalmology, Lode Lane, Solihull, West Midlands B91 2JL, United Kingdom.
Received: December 03, 2009
Accepted: February 05, 2010
Posted Online: May 21, 2010
Frontalis sling surgery is the surgical intervention of choice for ptosis, which is characterized by severely compromised levator function.1 Silicone tubes have been shown to be a suitable material for this procedure.2 Surgery for pediatric cases is often performed under general anesthesia,3 but the results are less satisfactory because the effect of gravity, the alertness of the patient, and brow position on the eyelid position cannot be assessed during the surgery without the patient in the erect position and a normal autonomic outflow. Surgery in adult cases is commonly performed under local anesthesia with active participation of the patient during the surgery. This report describes the authors’ experience using local anesthesia for a brow suspension procedure in a pediatric patient.
Bilateral brow suspension surgery was performed under local anesthesia in a 15-year-old boy with congenital ptosis and ocular fibrosis syndrome. The points for the stab incisions were marked (two directly above each brow and two at the eyelid margin). The eyelids and brows were infiltrated with 2% lignocaine with 1:100,000 adrenaline mixed with levobupivacaine 0.75% (in 50:50 mixes). The anesthetic was injected extremely slowly through a 30-gauge needle, in an effort to minimize pain, build up the confidence of the patient, and ensure cooperation during the procedure.
The stab incisions were performed by using a no. 11 blade. Two sets of silicone tubes2 were placed along the anterior boder of the tarsus. The material was then threaded under the orbicularis and sutured above the eyebrow so that contraction of frontalis muscle conveyed elevation of the upper eyelid. The tubes were secured with a silastic sleeve secured with a 6-0 polypropylene suture (one tier of slings from the brow to the eyelid margin with no second tier of slings to the forehead). This is our standard technique (Fig. 1). The tubes were tightened just enough to allow the eyelids to retain their supine position while the patient was erect. During the operation, the patient was asked to sit up to ascertain this correct tension, eyelid height, and contour and to ensure symmetry.
Figure 1. Intraoperative Assessment of Eyelid Position, Contour, and Symmetry with the Patient Sitting Up.
We achieved a symmetrical appearance and level of both upper eyelids in this patient under local anesthesia (Figs. 1 and 2).The patient tolerated the local anesthesia well and was discharged at the end of the surgery. The patient was satisfied with the anesthesia during the surgery and its outcome.
Figure 2. Immediate Postoperative Appearance.
The frontalis sling procedure is the treatment of choice in patients with severe ptosis and poor levator function. Although general anesthesia is preferred in pediatric patients, we find that local anesthesia is a viable alternative in selected older pediatric patients. Local anesthesia allows two-way communication between the surgeon and the patient, intraoperative eyelid position assessment, and hence optimal results.
Success depends on maintaining patient trust and this is achieved by a thorough preoperative discussion with the patient to allow him or her to anticipate each stage of the procedure. The surgeon should be careful not to lose patient trust with an overly hasty and painful injection of local anesthetic at the outset of the procedure.
The frontalis sling operation can be performed safely and effectively to correct ptosis in pediatric patients under local anesthesia. When done correctly with appropriate patient selection, the procedure is well tolerated.
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- Fogagnolo P, Serafino M, Nucci P. Stability of silicone band frontalis suspension for the treatment of severe unilateral upper eyelid ptosis in infants. Eur J Ophthalmol. 2008;18:723–725.
- Lancaster JL, Jones TM, Kay AR, McGeorge DD. Paediatric day-case otoplasty: local versus general anaesthetic. Surgeon. 2003;1:96–98. doi:10.1016/S1479-666X(03)80123-3 [CrossRef]