A NEW OPERATION FOR CONGENITAL AND PARALYTIC PTOSIS. By M. SARWAR, M.B., B.S., D.O.M.S. Ophthalmologist, United Oxford Hospitals

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1 A NEW OPERATION FOR CONGENITAL AND PARALYTIC PTOSIS By M. SARWAR, M.B., B.S., D.O.M.S. Ophthalmologist, United Oxford Hospitals THE various remedies for ptosis have never been really satisfactory, as is apparent from the number that have been used and recommended. This variety of surgical modes makes the problem attractive and worthy of investigation. A study of the literature shows that there are two ways of helping the patient-- the extraneous mechanical method and the surgical method. The mechanical method is the attachment of various devices to spectacle frames, e.g., the ptosis bar. This method has all the disadvantages common to mechanical corrective gadgets. The surgical method: there are about fourteen different procedures with more than thirty modifications. In the following table an attempt has been made to classify them. Classification of Ptosis Operations.-- I. Removal of skin only. 2. Use of the frontalis to lift the lid. (a) Anchoring the lid to the frontalis by strips of skin. (b) Anchoring the lid to the frontalis by sutures (Hess and others). (c) Anchoring the lid to the frontalis by fascia lata sutures. (d) Attaching the levator palpebra: to the frontalis. (e) Frontalis strip brought down and anchored to the lid (Fergus, modified by Roberts). 3. Surgery on the levator tendon (Everbusch, Blaskovics). 4- Use of the superior rectus as an elevator (Motais, Greaves). (a) Directly by attaching the muscle to the tarsus (Kirby, Weiner, and others). (b) Lid sutured to the globe (Young). (c) Fascia lata sling (Dickey). (d) Strip of tarsus passing behind the rectus (Trainer). (e) Strip of orbicularis attached to the superior rectus (Wheeler). 5- Strips of orbicularis from near the lid margin slung up to the frontalis (Rees, Hunt-Tansley). Considering these operations group by group, skin excision, though simple to carry out, never gives a permanent result because the scar stretches after some time and the lid droops again. Operations in Group 2, though otherwise satisfactory, make the patient frown all the time, and do not allow normal closure of the lid. Operations in Group 3 are admirable and correct procedures in cases where there is some action in the levator, or when the levator is unduly long, as they are mainly in the nature of a shortening of the levator, but they fail when the ptosis is due to a complete paralysis or to congenital absence of the muscle. 293

2 294 BRITISH JOURNAL OF PLASTIC SURGERY Operations in Group 4 cause a depression of the globe, and the resulting hypophoria produces diplopia, which may be intractable. Moreover, the patient has to learn to defeat physiology by training himself to look down when he wants to shut his eyes. A common drawback of all is an inability of varying degree to shut the eyes. Knowing that re-education of the muscles is possible, and that strips of the fascial muscle sheet could be made to work at will with training as by actors, it was considered possible to make a strip of orbicularis work as a false levator by attaching it to the tarsal plate, and so the following operation was devised. Technique.--Ancesthesia.--Local infiltration of the lid, with surface ana:sthesia of the conjunctival sac, or general ana:sthesia may be used depending on circumstances. If a general ana:sthetic is chosen, the lid should be infiltrated with novocaine and adrenaline to control oozing, which may be troublesome. Special Instruments.--Halstead's mosquito forceps; Desmarres entropion forceps ; double-armed catgut suture ooo on No. 6 needles. Procedure.--(I) The lid is held in the entropion forceps. (2) A I5-mm. long incision is made about 5 mm. above and parallel to the lid margin. The upper border of the tarsal plate is exposed with a little dissection, as in Figs. I and 2. (3) A second incision parallel to and longer than the first is made just under the supraorbital margin, and the uppermost fibres of the orbicularis are exposed (Fig. 3)- (4) The highest fibres of the orbicularis are then identified. A vertical cut about 3 mm. long is made medial to the medial edge of the supraorbital notch. (5) The double-armed catgut suture is inserted in the medial lip of this cut. (6) The lateral lip of the cut is separated outwards as a strip. This is dissected outwards until the strip is about I¼ to I] in. long (Fig. 4). (7) A pair of blunt-pointed scissors are then inserted in the space made by the dissection of the strip, and worked downwards between the orbicularis and the levator muscle (preorbital fascia if the levator is absent) until they appear on the tarsal plate in the first incision, so making a tunnel. (8) The middle portion of the levator tendon, if present, is detached from the tarsal plate, and the conjunctiva on the back of the plate is separated from it. (9) An incision about 3 mm. long and 2 or 3 ram. from the upper border of the tarsus is now made, cutting through the whole thickness of the plate. (IO) The mosquito forceps (closed) are now passed upwards along the tunnel (step 7) ; the end of the strip of orbicularis is picked up and brought down (Fig. 5). It is pulled through the incision in the tarsal plate (step 9) from behind forwards. The strip is picked up again in the mosquito forceps and taken upwards along the tunnel (Fig. 6). (I I) The double-armed suture (step 5) is now passed through the end of the strip as a mattress suture and tied. This pulls up the lid (Fig. 7). (x2) Excess of skin is excised and the skin incision closed with subcuticular sutures (Figs. 8 and 9). (I3) The lower lid is pulled up by means of an anchor stitch. The eye is dressed with tulle gras. The first dressing is changed on the sixth day and the stitches are removed on the eighth day.

3 CONGENITAL AND PARALYTIC PTOSIS Post-operative Anatomy.--The anteroposterior relations of structures after operation are: skin, superficial fascia, orbicularis orbicularis loop, levator tendon and tarsal plate, conjunctiva. 295 the eyelid oculis, the FIGS. 1-9 KEY TO THE PHOTOGRAPHS OF THE OPERATION In this case the orbicularis strip was taken from the outer third of the muscle fibres as a variant. I. First incision. 2. Dissection for exposing the upper border of the tarsus. 3- Second incision. 4. Orbicularis strip dissected inwards. 5. Muscle strip brought down to the upper border of the tarsus. 6. The strip through the tarsus. 7. Suturing the strip to form the sling. 8. Excess of skin being removed. 9. Closure. Case Reports.--(i) D. T., aged 24. A case of bilateral congenital ptosis. The patient had been wearing a ptosis bar since childhood. His right eye was operated on 3rd February I949, the left eye on I4th February I949. The result was satisfactory. 4 F

4 296 BRITISH JOURNAL OF PLASTIC SURGERY (2) R. G., aged I9. A case of congenital ptosis of the right eye which had been operated on elsewhere. The Trainor technique had been used. The result was cosmetically good, but there was persistent diplopia due to a weakness of the superior rectus, and the lid closure was not satisfactory. Four months after this with the diplopia still persisting it was decided to operate again, using the " new orbicularis sling." The operation was performed on 23rd March 195 o, and the superior rectus was freed at the same time. The result was satisfactory. The diplopia disappeared and a satisfactory opening and closure of the lid was obtained. FIG. IO FIG. II Eyes open. Before operation. Eyes wide open. Before operation. FIG. I2 FIG. x3 FIG. 14 Eyes open. After operation. Eyes wide open. Showing normal closure. After operation. After operation. (3) W. N., aged 46. A case of left congenital ptosis and superior rectus paralysis which had been operated on thirty-eight years ago. Judging by the scar, the operation was one of Group z and it had not been successful. In May i95 o he was operated on again, using the "new orbicularis sling" technique. The superior rectus was advanced at the same time. Satisfactory movement of the lid was obtained, and the eye was brought into line with the other eye. The superior rectus being completely paralysed, there was no upward movement of the eye. So far eight patients and ten eyes have been operated on with satisfactory results and no complications. The photographs are of Case 5-

5 CONGENITAL AND PARALYTIC PTOSIS 297 DISCUSSION Case I was shown to Professor Kilner, who thought that the orbicularis strip probably acted in the same way in this operation as in a fascia lata or other sling attaching the lid to frontalis. The same criticism was offered by others, notably by Mr C. D. Shapland, when this case was shown at the Royal Society of Medicine, Section of Ophthalmology. It should be noted that the muscle strip in this operation is not attached to the frontalis in any way. However, to investigate this possibility, an attempt was made to obtain an electromyograph of the muscle strip. This was carried out by Dr George Gordon of the Department of Physiology at Oxford, who took great pains in making specially fine needle electrodes for the purpose of insertion into the muscle strip. The tests were carried out on Case I. In spite of the special needles it was felt at the outset that it would be difficult to hit the narrow strip and get a proper reading ; nevertheless, the attempt was made. The needle was inserted several times along the probable course of the " sling," but only normal orbicularis reactions were obtained. At one point a small upshoot was obtained which conformed to the assumed action of the strip, but Dr Gordon considered this an artefact. In spite of lack of confirmatory- electromyogram, the clinical fact is that the lids open normally, and this movement is further increased by effort when the frontalis comes into play. Another point is that the movement is a mere flicker soon after the operation, and improves with time. If one assumes that the muscle strip acts as a mere sling, the primary opening of the lid can be explained by the action of the superior rectus. If this were the case, the operation would have failed in Case 3, where the superior rectus was paralysed and there was no upward movement of the eye. As the lid movement in Case 3 is the same as in the other cases, it can be claimed with justice that the muscle strip stays active and acts as a false levator. Another question which arises is whether this muscle strip becomes retrained for its new action--the assumption on which this operation was devised--or have the upper fibres of the orbicularis, from which the strip was taken, a different function from that of the lower fibres? Considering the fact that movement of the lid is present when the bandage is removed for the first dressing, it would appear that the two sets of fibres have different functions. The upper fibres, I think, contract when the lid is opened to take up the" slack of the lid "on opening, and so the strip of muscle which belongs to these fibres and is diverted through the tarsus with its origin and insertion intact contracts in its normal way and pulls the tarsus up with it. I am indebted to Professor Kilner for his criticisms and to Miss Campbell and Dr John Ogg for taking the photographs. My thanks are due to Mr R. S. MacLatchy, Ophthalmic Surgeon, Horton Hospital, Banbury, and Mr M. Hatfield Wright, Ophthalmic Surgeon, Swindon, and Military Hospital, Wheatlev, for allowing me to operate on their patients and giving me hospital facilities for the work. I am grateful to Dr George Gordon for the electromyograms. I have also to thank my wife, Dr Margaret Ford, for her encouragement and for assisting me with the writing of this article. 4 E~