13.1 Patient History Leading to Upper Eyelid Ptosis

This is a 53-year-old woman with a history of thyroid ophthalmopathy associated with exophthalmos and upper and lower eyelid retraction (Fig. 13-1). She was treated with a bilateral four-wall orbital decompression, excision of the upper eyelid Müller muscle and levator recessions, bilateral lateral canthoplasties, and excision of herniated orbital fat. Postoperatively, she had a left upper eyelid ptosis with secondary loss of superior peripheral vision and difficulty reading due to closure of her left eyelids in the down-position of gaze.

Hertel exophthalmometry readings were 20.5/105 on the right and 20/105 on the left.

13.2 Anatomical Description of the Patient’s Current Status

The left upper eyelid ptosis was due to the excision of the Müller muscle and recession of levator aponeurosis. It was done to lower her retracted left upper eyelid. The orbital decompression to treat her exophthalmos also contributed to the ptosis by the sinking inward and downward of the eye (Fig. 13-1).

13.3 Recommended Solution to the Problem

• 
  

  A vertical resection of full-thickness eyelid from the crease incision site.

  
  
• 
  

  The amount of resection is based on the amount of ptosis, with a resection of a millimeter of full-thickness tissue for each millimeter of ptosis.

  
  
• 
  

  Thus, if there are 3 mm of ptosis, 3 mm of full-thickness eyelid is resected.

  
  
• 
  

  The amount of resection is varied nasally, centrally, and temporally, depending on the amounts of the ptosis at each of these segments to create a more normal upper eyelid arch.

  
  
• 
  

  The resection of full-thickness tissue is done below or above the present crease, depending on if there is an abnormally high or low crease and fold.

  
  
• 
  

  Therefore, if the distance from the present eyelid crease is large, there is a resection of full-thickness tissue below the crease-incision site.

13.4 Technique

A sterile surgical marking pen is used to delineate the predetermined eyelid crease on the upper eyelid and local anesthetic is injected subcutaneously (Fig. 13-2a).

The upper eyelid is everted over a Desmarres retractor and local anesthetic is infiltrated subconjunctivally at the superior tarsal border (Fig. 13-2b).

After placing a 4–0 silk traction suture in the upper eyelid margin, a #15 Bard-Parker blade and Colorado needle are used to create an eyelid incision. Hemostasis is performed with a disposable cautery (Fig. 13-2c).

A full-thickness incision is made across the entire upper eyelid (Fig. 13-2d).

When the margin distance on the ptotic eyelid is elevated in comparison to the contralateral eyelid, a full-thickness resection of tissue is removed inferior to the crease incision site (Fig. 13-2e).

A 6–0 double-arm Vicryl suture is then passed through the central lower eyelid portion of the wound with care given to avoid suture contact with the globe. Often, the sutures pass through tarsus; both arms of the suture then pass securely through the upper portion of the wound (Fig. 13-2f). Care is taken to imbricate the levator muscle but not to pierce the conjunctiva.

The suture is then tied with two throws of a surgeon’s knot, over a knot-releasing piece of 4–0 silk suture (Fig. 13-2g).

The contact lenses are removed from the patient’s eyes and the patient is sat upright. If the lid level is too high or low, the 4–0 suture is pulled to release the knot and the sutures are replaced lower or higher, respectively.

The remaining wound is first closed with the open arms of the 6–0 Vicryl suture used to imbricate the underlying levator muscle (Fig. 13-2h).

The wound is finally closed with a running 6–0 silk suture (Fig. 13-2i).