Review on surgical management of ptosis and the use of phenylephrine: A national survey of British Oculoplastic Surgery Society (BOPSS) UK Consultants

Abstract

We assess current practice using topical phenylephrine by British Oculoplastic Surgery Society (BOPSS) consultants in the surgical management of ptosis. All UK consultant BOPSS members were invited to participate in a web-based survey, consisting of 8 questions relating to the surgical management of adult primary involutional ptosis with normal levator function and the use of phenylephrine in the management of ptosis. 53 BOPSS consultants (43%) completed the survey, of which 76% perform anterior approach levator advancement as first-line surgery. Then, 40% of consultants routinely use phenylephrine unilaterally in the ptotic eye, with 90% using 2.5% as opposed to 10%. Also, 77% of consultants use topical phenylephrine to illustrate the predicted outcome of surgery for the patient's benefit and 65% modify their approach on the basis of the test. If phenylephrine raises the ptotic eyelid >2 mm, those using an anterior approach reduces to 13.6%, with majority using a posterior approach (86.4%). If phenylephrine induces no improvement, then 76% use an anterior approach. If phenylephrine induces a contralateral ptosis 79% of consultants will perform simultaneous bilateral surgery. A number of interesting trends were observed amongst BOPSS consultants in their surgical approach to ptosis based on the phenylephrine test. The majority of consultants will switch from anterior to posterior approach surgery when the phenylephrine test is strongly positive and will also perform bilateral surgery when a contralateral ptosis is induced with phenylephrine.

Relationship between the phenylephrine test and eyelid droop after aponeurotic repair with the use of an epinephrine-containing local anaesthetic

“…Finally, only 5% phenylephrine eye drops are commercially available in Japan, although 2.5% phenylephrine eye drops are commonly used in other countries. 25,26 A previous study showed more cardiovascular adverse effects after 10% phenylephrine instillation, compared with 2.5% phenylephrine instillation. 27,28 Although we used 5% phenylephrine eye drops, this may cause a greater risk of adverse side effects than 2.5% phenylephrine instillation.…”

Updates in the function and regulation of α1‐adrenoceptors

“…Thus, α 1adrenoceptor agonists such as phenylephrine, are components of oral over-the-counter medications to alleviate the congestive symptoms of the common cold and influenza. In addition, the imidazolines, oxymetazoline and naphazoline, are common components of topical nasal decongestants, mydriatic eye drops, and more recently dermatological formulations for the treatment of facial erythema in rosacea (Kircik et al, 2018;Mota & Norris, 2016;Vaidyanathan, Williamson, Clearie, Khan, & Lipworth, 2010). Interestingly, oxymetazoline and naphazoline are low efficacy agonists with reasonable selectivity for α 1Aadrenoceptors (10-to 30-fold; Akinaga et al, 2013;Minneman, Theroux, Hollinger, Han, & Esbenshade, 1994), further supporting the relevance of this subtype in vasoconstriction.…”

How far we have come: A review of the evolution of posterior approach ptosis surgery

“…In the United Kingdom, 77% of surgeons use phenylephrine testing to demonstrate an idea of surgical outcome to the patient, whereas 62% use it to detect subclinical contralateral ptosis …”

“…50 In the United Kingdom, 77% of surgeons use phenylephrine testing to demonstrate an idea of surgical outcome to the patient, whereas 62% use it to detect subclinical contralateral ptosis. 51 About 65% of surgeons used phenylephrine testing to determine their surgical approach, utilizing a posterior approach for >2 mm lid elevation with phenylephrine testing and an anterior approach for <2 mm lid elevation. 51 But is this importance attributed to phenylephrine testing justified?…”

“…51 About 65% of surgeons used phenylephrine testing to determine their surgical approach, utilizing a posterior approach for >2 mm lid elevation with phenylephrine testing and an anterior approach for <2 mm lid elevation. 51 But is this importance attributed to phenylephrine testing justified? Dr Putterman's group reported that small amounts of difference in tarsal resection in MMCR do not make a difference to the postoperative lid height, however preoperative phenylephrine testing is more predictive.…”