Surgical treatment of congenital blepharoptosis

Abstract

A blefaroptose é o posicionamento inadequado da pálpebra superior, estando abaixo de sua posição normal na posição primária do olhar, a qual seria 0,5 -2mm abaixo do limbo superior. Pode causar bloqueio parcial ou completo do campo visual superior, além do comprometimento estético. As causas são categorizadas em congênitas ou adquiridas. É considerada congênita se presente ao nascimento ou diagnosticada no primeiro ano de vida. As principais técnicas utilizadas para o tratamento da ptose congênita são a ressecção da aponeurose do músculo levantador da pálpebra superior (MLPS) e a suspensão frontal. A medida da função do MLPS é o parâmetro mais importante na escolha da técnica cirúrgica. Quando a função é fraca, a suspensão frontal é mais indicada; a ressecção supramáxima do MLPS também pode ser empregada. Acima de 4 ou 5mm de função do MLPS, prefere-se a ressecção da aponeurose. Para a cirurgia de suspensão frontal, vários são os materiais utilizados, portanto apresentamos uma comparação entre os estudos mais relevantes. Discutiremos também particularidades em casos mais complicados, como as Síndromes da Blefarofimose e de Marcus-Gunn, além de técnicas cirúrgicas menos utilizadas e as complicações relatadas. ABSTRACT RESUMOThe blepharoptosis is the improper positioning of the upper eyelid, being below its normal position in primary gaze, which is 0.5 -2mm below the superior corneal limbus. It may block partially or completely the upper visual field, and lead to aesthetic commitment. The causes are categorized as congenital or acquired. It is considered congenital if present at birth or diagnosed during the first year of life. The main techniques used for the treatment of congenital ptosis are the resection of the levator muscle aponeurosis and the frontalis suspension. The function of the levator muscle is the most important parameter to define the surgical technique. When the function is weak, the frontalis suspension is more appropriate; the supra-maximal resection of the levator muscle may also be employed. With function above 4 or 5mm, the resection of the aponeurosis is preferred. For the frontalis suspension surgery, various materials can be used, so we present a comparison of the most relevant studies. We also discuss some characteristics in more complicated cases, such as the Blepharophimosis syndrome and the Marcus-Gunn syndrome, and surgical techniques less performed and complications reported.

Frontalis sling surgery: do we really need the Wright needle?

“…Another variation of the Fox technique, modified by Friedenwald-Gyton (5,6,11) was the performance of only two incisions near the top edge of the eyebrow (also called simple rhomboid technique), one medial and another lateral, avoiding the upper incision, as we find it more aesthetic. The knotting of the silicon rod was done in the eyebrow's lateral incision.…”

“…Still, prospective randomized trials are required to confirm the superiority of silicone over the fascia lata and to compare silicone with other materials. Studies have also shown that nylon, Mersilene and polytetrafluorethylene (PTFE or "Gore-tex") also have good acceptance, but show varying rates of extrusion, infection, and granuloma formation (11) .…”

“…The surgical technique used has been described by Friedenwald-Gyton (5,6,11) with some technical changes. General anesthesia or intravenous sedation plus a local anesthetic with 2% lidocaine and 0.75% bupivacaine was used.…”

“…In 1966, Tillet and Tillet first described the use of silicone in frontalis suspension to correct ptosis. In the mid-20th Century, authors such as Berk, Jones and Beard systematized surgical techniques and concepts (11) .…”

Clinical efficacy of conjoint fascial sheath suspension and frontalis muscle suspension in treating moderate or severe congenital ptosis and the effects on ocular surface and refractive status

“…Such a situation in a child at birth or in the first year after birth can be diagnosed as congenital ptosis, and unilateral ptosis accounts for 64.7-75.0% of all types of ptosis ( 1-3 ). Congenital ptosis can be classified into mild, moderate, or severe ptosis ( 4 ), which is mainly caused by the following reasons: The upper eyelid cannot lift or is in partial or complete ptosis due to hypoplasia of levator muscle, defects of Müller smooth muscle, or nerve defects of upper eyelid muscle ( 5 , 6 ). Ptosis usually causes partial or complete pupillary block, and thus results in visual disturbance.…”