21.1 Introduction

Müller’s muscle–conjunctival resection (MMCR) is a surgical procedure for correction of 1 to 3 mm of ptosis from a posterior approach. This procedure was originally described by Putterman and Urist to correct minimal to moderate ptosis in patients with good levator excursion. ^{1 ,​ 2} Modified techniques have been described by Weinstein and Buerger, Guyuron and Davies, and Dresner. ³ ID#b120a000_4 ^{– 5}

21.2 Indications

Candidates for this procedure have minimal to moderate ptosis, ranging from 1 to 3 mm of ptosis, good levator excursion (> 10 mm), normal contour, and a positive phenylephrine test (Fig. 21.1). Preoperatively, the margin reflex distance 1 (MRD1) is measured in both upper eyelids. Phenylephrine (2.5%) is applied to the ptotic eye or eyes. The MRD1 is then rechecked in both eyes in 3 to 5 minutes. A response of 2 mm or more upper eyelid elevation is a positive result, and one can proceed with surgical planning.

A nomogram has been developed that gives accurate guidelines for how much Müller’s muscle and conjunctiva to resect for the measured amount of ptosis (Fig. 21.2). For 1 mm of ptosis, a 4-mm resection of Müller’s muscle is planned. For 1.5 mm of ptosis, a 6-mm resection is planned. For 2 mm of ptosis, an 8-mm resection is planned. If 3 mm of ptosis is present, a 10-mm resection can be performed; however, the nomogram is less predictable in larger amounts of ptosis.

21.3 Risks

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  Overcorrection.

  
  
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  Undercorrection.

  
  
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  Corneal abrasion.

  
  
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  Bleeding.

21.4 Benefits

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  Predictable amount of eyelid lift.

  
  
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  Easily performed in office setting with minimal patient discomfort.

21.5 Informed Consent

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  Include risks and benefits.

21.6 Contraindications

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  Cicatrizing conjunctival disease like mucous membrane pemphigoid.

  
  
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  Severe dry eye and exposure keratopathy may lead the surgeon to do a smaller eyelid elevation.

  
  
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  Prior glaucoma surgery in the superior conjunctiva and, in particular, large trabeculectomy blebs are a relative contraindication.