Upper Eyelid Ptosis Repair after Cataract Extraction and the Importance of Heringʼs Test

Abstract

Blepharoptosis is a well-documented complication of cataract extraction and other ocular procedures. Few authors have described the surgical findings and outcomes of postcataract blepharoptosis repair. The authors present a review of the causes of postcataract blepharoptosis with emphasis on both clinical findings and recommendations for treatment on the basis of their experience with 13 eyelids in eight patients over the past 10 years. They found that all patients had either partial or total disinsertion of the levator muscle from the tarsal plate. Of the eight patients in this series, five had bilateral blepharoptosis after bilateral cataract extraction. Although a multifactorial cause for postcataract blepharoptosis is commonly assumed, the authors propose that the mechanical forces of intraoperative traction on the levator aponeurosis during cataract surgery are the primary cause. This is further supported by their operative findings in the five patients who developed bilateral ptosis after bilateral cataract extraction. All eyelids in this series were repaired by levator muscle advancement and attachment to the tarsal plate with favorable outcomes and no recurrences during a 1-year follow-up. The importance of Hering's phenomenon of equal innervation is also discussed as it applies to bilateral and to apparent unilateral blepharoptosis. The authors propose "Hering's test" as an important indicative study in the preoperative evaluation of all patients with eyelid ptosis.

Effect of Unilateral Blepharoptosis Repair on Contralateral Eyelid Position

“…Although Hering described his law of equal innervation to the extraocular muscles, later observers have sought to apply Hering law to the levator palpebrae superioris. [5][6][7][8][9][10][11] When a patient attempts to clear the visual axis from asymmetric blepharoptosis in the more ptotic eye, this will induce increased innervation to both levators, with resultant contralateral upper eyelid retraction, possibly masking mild blepharoptosis. With surgical elevation of the more ptotic eyelid, innervation to both levator superioris muscles lessens, which may manifest the masked contralateral ptosis after surgery.…”

Blepharoptosis following ocular surgery

“…This topic is not likely to be discussed in depth preoperatively, and may result in decreased patient satisfaction and quality of life postoperatively [7]. Repair of postoperative ptosis is correctable with high rates of success [41], but requires the patient to undergo an additional surgical procedure and its associated risks, and should be discussed as a possibility prior to the initial ocular surgery.…”

“…Ptosis following ocular surgery can be treated with high rates of success [2,5,7,[41][42][43][44][45]. These treatments restore or recreate the structure-function relationships within the upper eyelid using multiple surgical approaches (Fig.…”

Eyelid Malposition After Cataract and Refractive Surgery

“…The contralateral eye should also be examined and the effect of Hering law should be evaluated by elevating the ptotic eye to uncover any masked ptosis in the contralateral eye. 41,42 Ptosis has been shown to be variable during the initial 6 months postoperatively, and thus it is important to wait for 6 months before performing ptosis repair. 7 It may be advisable to wait 1 full year before repair, as spontaneous return of levator function even 11 months after cataract extraction has been described.…”