Purpose
To compare outcomes of conjunctival Müllerectomy with or without tarsectomy versus external levator advancement for correction of upper blepharoptosis when performed by trainee versus staff surgeons.
Design
Retrospective, nonrandomized, interventional, consecutive case series.
Methods
Charts of patients undergoing conjunctival Müllerectomy with or without tarsectomy and external levator advancement blepharoptosis repair from January 2006 through December 2009 were reviewed. Main outcome measures included age, gender, preoperative and postoperative use of artificial tears, preoperative and postoperative marginal reflex distance, surgical complications, surgeon (trainee or staff surgeon), and anesthesia time. The Student t test was used for statistical analysis.
Results
A total of 170 patients underwent 248 surgeries (154 conjunctival Müllerectomies with or without tarsectomy and 94 external levator advancements). There were 108 female and 62 male patients. Mean patient age was 62 years (range, 3 to 94 years). Forty-one (24%) patients (26 conjunctival Müllerectomies with or without tarsectomy and 15 external levator advancements) underwent concurrent eyelid surgery, such as blepharoplasty. Trainees performed surgery on a total of 88 (35%) eyelids in 60 patients (35%). There was no significant difference in the percentage of cases undergoing concomitant surgery between trainee and staff surgeons ( P = .18). The mean postoperative marginal reflex distance difference was 0.53 and 0.59 for trainee and staff surgeons, respectively. Mean overall anesthesia time was 26.8 minutes and 30.3 minutes for trainee and staff surgeons, respectively. Complications, including increase in dry eye or irritative symptoms and reoperation, occurred in 8 (13%) of 60 patients undergoing surgery by a trainee surgeon and in 22 (20%) of 110 patients undergoing surgery by staff surgeon. There was no significant difference in eyelid symmetry ( P = .55), mean anesthesia time ( P = .14), complication rate ( P = .26), or reoperation rate ( P = .17) when surgery was performed by a trainee versus a staff surgeon.
Conclusions
There is no significant difference in mean postoperative marginal reflex distance, mean anesthesia time, complication rate, or reoperation rate between either conjunctival Müllerectomy with or without tarsectomy or external levator advancement blepharoptosis repair performed by trainee versus staff surgeons.
Blepharoptosis represents a common eyelid malposition with a variety of causes. Both conjunctival Müllerectomy with or without tarsectomy and external levator advancement ptosis repair improve eyelid position with excellent success rates. Trainees at the Cole Eye Institute routinely perform both types of blepharoptosis repair, often with concomitant eyelid surgeries, such as blepharoplasty.
Several studies evaluate other ophthalmologic surgeries performed by the trainee versus an attending (staff) surgeon. Given that conjunctival Müllerectomy with or without tarsectomy does not require intraoperative adjustments or specialized techniques to optimize eyelid height and contour, whereas levator advancement does require such techniques, it seems plausible that levator advancement may incur poorer outcomes when performed by a trainee.
Indeed, some ophthalmologic surgeries, such as penetrating keratoplasty and cataract extraction, may result in worse outcomes when performed by trainees. Randleman and associates reported that 64.6% of grafts performed by resident surgeons remained clear, whereas a different study of experienced surgeons using similar exclusion criteria showed graft survival of 89%. Cataract surgery performed by trainees may produce a vitreous loss rate of between 1.3% and 14.7%, whereas in the hands of an experienced surgeon, it may be less than 1%. None of these studies directly compared outcomes at the same institution when surgery was performed by the trainee or by an attending staff surgeon.
Although some studies point to poorer results from surgery by trainees, others show similar results. The rate of rhegmatogenous retinal detachment after cataract surgery performed by residents may be as low as 0.76%. This compares favorably with published rhegmatogenous retinal detachment rates in the hands of experienced surgeons ; however, a direct comparison between surgeon groups was not performed. Strabismus surgery performed by residents and attending surgeons may have similar outcomes as well.
Regarding oculoplastic surgical procedures, external dacryocystorhinostomy may result in similar outcomes when performed by a trainee and an experienced surgeon. In one study, 96 (78%) out 123 patients reported full resolution of symptoms when operated on by a trainee, whereas 105 (76.6%) of 137 patients reported full resolution when operated on by an experienced surgeon ( P = .78).
Interestingly, despite the importance and ubiquity of ophthalmologic surgery performed by trainees, most studies do not compare directly results of trainees with those of experienced surgeons. We sought to compare the outcomes of blepharoptosis repair in the hands of trainees versus the educating staff surgeon at the same institution.
Methods
This study was approved prospectively by the Cleveland Clinic Institutional Review Board for a retrospective review of patient charts as well as the collection, analysis, and publication of deidentified patient data.
We respectively reviewed the medical records of all patients undergoing conjunctival Müllerectomy with or without tarsectomy or levator advancement blepharoptosis repair at the Cole Eye Institute between January 2006 and January 2010. Only patients with incomplete medical records were excluded from the study. Data collected included the following: age, sex, preoperative and postoperative use of artificial tears, preoperative and postoperative marginal reflex distance, surgical complications, surgeon (trainee or staff), and operative time. Patients returned approximately 1 week after surgery for suture removal and between 6 weeks and 3 months after surgery. The marginal reflex distance recorded from the final follow-up visit was used for data analysis. All patients were evaluated by the senior author (J.D.P.) in a faculty practice. The senior author (J.D.P.) determined the type and amount of surgery and the primary surgeon in each case.
Both surgical procedures were performed similarly to previously published techniques. Surgeries by trainees were supervised by the same surgeon (J.D.P.) who performed the staff surgeries. Surgeries performed by the fellow were supervised by the attending surgeon for the key elements of the surgery.
The algorithm and technique for tissue resection in conjunctival Müllerectomy with or without tarsectomy surgeries was performed according to a previously published technique of one of the authors (J.D.P.). Briefly, this algorithm called for resection of 9 mm of conjunctiva and Müller muscle plus X mm of tarsus, where X = the amount of undercorrection after phenylephrine 10% testing. The technique used a Putterman ptosis clamp and an externalized 6-0 polypropylene suture to secure the unresected tissue. The key elements of conjunctival Müllerectomy with or without tarsectomy ptosis repair constituted the placement of the clamp and suturing the tissues beneath the clamp.
Patients with a superior filtering bleb, penetrating keratoplasty, anophthalmic socket, or ptosis of more than 3 mm underwent levator advancement blepharoptosis repair similar to the technique described by Lucarelli and Lemke. In these eyelids, a 1-cm incision was made centrally with a no. 15 blade, with dissection performed superiorly along the septum with Westcott scissors. Westcott scissors then were used to open the orbital septum and to disinsert the aponeurosis from the tarsus. The levator aponeurosis then was advanced with 1 5-0 Mersilene suture in a lamellar fashion. The key elements of levator advancement ptosis repair included dissecting the levator aponeurosis from tarsus and advancing the aponeurosis. When levator advancement was performed in conjunction with other surgery such as blepharoplasty, still only 1 suture was used to advance the aponeurosis, and the same dissection of the levator muscle took place.
Primary outcome measures included the following:
- 1.
Eyelid symmetry as measured by marginal reflex distance between the 2 eyes of each individual patient. Marginal reflex distance was measured before and after surgery without brow fixation. Excellent symmetry was defined as a postoperative marginal reflex distance difference within 0.5 mm, whereas satisfactory symmetry was defined as a postoperative marginal reflex distance difference of between 0.5 and 1.0 mm, and poor symmetry was defined as a postoperative marginal reflex distance difference of greater than 1.0 mm.
- 2.
Anesthesia time, as measured by total in-room time (an average of the time recorded on chart outcomes forms and anesthesia forms.
- 3.
Surgical complications, which included the new-onset or increase in dry eye or irritative symptoms, edema, pain, foreign body sensation, lagophthalmos, or corneal irritation that persisted after 1 month. A mild increase in dry eye or irritative symptoms was defined as an increase in artificial tears to up to 3 drops per day. A moderate increase in dry eye or irritative symptoms was defined as an increase in artificial tears between 4 and 6 times per day or requiring punctal plugs. A severe increase in dry eye or irritative symptoms was defined as requiring more surgery.
Statistical analysis was performed using a 2-sample t test assuming unequal variances to analyze primary outcome measures.
Results
Charts of 170 patients undergoing conjunctival Müllerectomy with or without tarsectomy and levator advancement blepharoptosis repair were included for review in this study. Charts of 25 other patients were excluded because of incomplete records. There were 108 females and 62 males with the average age of 62 years (range, 3 to 94 years). Mean follow-up after surgery was 75 days (range, 6 to 626 days). Conjunctival Müllerectomy with or without tarsectomy was performed on 154 eyelids in 103 patients (61%), including 4 unilateral reoperations in 4 patients (2%). Levator advancement was performed on 94 eyelids in 67 patients (39%), including 3 unilateral reoperations in 3 patients (2%). Twenty-six (25%) of the 103 patients who underwent conjunctival Müllerectomy with or without tarsectomy and 15 (22%) of the 67 patients who underwent levator advancement also underwent concomitant procedures, such as blepharoplasty. Ninety-nine patients (58%) (56 undergoing conjunctival Müllerectomy with or without tarsectomy and 43 undergoing levator advancement) underwent unilateral surgery, whereas 71 patients (47 undergoing conjunctival Müllerectomy with or without tarsectomy and 24 undergoing levator advancement) underwent bilateral correction. Table 1 summarizes the demographic data.
| Demographics | Conjunctival Müllerectomy With or Without Tarsectomy | External Levator Advancement | Overall |
|---|---|---|---|
| Gender | |||
| Male | 38 | 24 | 62 |
| Female | 65 | 43 | 108 |
| Mean age (range), years | 62.3 (12 to 92) | 60.8 (3 to 94) | 61.7 |
| Operative eye | |||
| Unilateral | 56 | 43 | 99 |
| With concomitant procedures | 10 | 5 | 15 |
| Bilateral | 47 | 24 | 71 |
| With concomitant procedures | 16 | 10 | 26 |
| Surgeon | |||
| Trainee | 48 | 12 | 60 |
| Staff | 55 | 55 | 110 |
| Mean follow-up (range), days | 60.1 (6 to 377) | 97 (6 to 626) | 74.6 |
| Patients using preoperative artificial tears | 33 | 18 | 51 |
Trainees, which included residents and fellows, performed surgery on a total of 88 (35%) eyelids in 60 patients (35%). Bilateral conjunctival Müllerectomy with or without tarsectomy was performed on 47 eyelids in 23 patients (14%), with 6 patients undergoing concomitant procedures. One patient undergoing trainee-performed bilateral conjunctival Müllerectomy with or without tarsectomy required unilateral reoperation. Unilateral conjunctival Müllerectomy with or without tarsectomy was performed on 25 eyelids in 25 patients (15%), with no reoperations, and 4 patients (2%) underwent concomitant procedures. Bilateral levator advancement was performed on 8 eyelids in 4 patients (2%), with 1 patient having a concomitant procedure. Unilateral levator advancement was performed on 8 eyelids in 8 patients (5%). No levator advancement patients who underwent surgery by a trainee required reoperation.
The staff surgeon performed surgery on a total of 160 (65%) eyelids in 110 patients (65%). Bilateral conjunctival Müllerectomy with or without tarsectomy was performed on 50 eyelids in 24 patients (14%), with 2 patients (1%) requiring unilateral reoperations. Ten of the patients undergoing bilateral conjunctival Müllerectomy with or without tarsectomy (42%) also underwent concomitant procedures. Unilateral conjunctival Müllerectomy with or without tarsectomy was performed on 32 eyelids in 31 patients (18%), with 1 patient requiring a reoperation, and 6 patients (4%) underwent concomitant procedures. Bilateral levator advancement was performed on 40 eyelids in 20 patients (12%), and 9 patients (5%) underwent concomitant procedures. Unilateral levator advancement was performed on 38 eyelids in 35 patients (21%), with 3 patients (2%) requiring reoperation, and 5 patients (3%) underwent concomitant procedures. There was no significant difference in the percentage of eyelids undergoing concomitant surgery between trainee and staff surgeons ( P = .18).
In cases of conjunctival Müllerectomy ptosis repair, tarsectomy was performed in 45 (63%) of 72 eyelids for trainee surgeries and in 51 (62%) of 82 eyelids for attending surgeries. This difference was not statistically significant ( P = .95).
Eyelid Symmetry
The overall preoperative marginal reflex distance difference between the eyes were 1.80 and 1.60 mm ( P = .32) for surgeries performed by trainee and staff surgeons, respectively. The overall average difference in postoperative marginal reflex distance was 0.53 mm (range, 0 to 3 mm) for surgeries performed by a trainee and 0.59 mm (range, 0 to 3 mm) for surgeries performed by a staff surgeon. This difference was not statistically significant ( P = .55).
For the conjunctival Müllerectomy with or without tarsectomy surgery subgroup, trainees achieved an average postoperative marginal reflex distance difference of 0.49 mm (range, 0 to 2.5 mm), with excellent symmetry in 59 (82%) of 72 eyelids of 38 (79%) of 48 patients. The staff surgeon achieved an average postoperative marginal reflex distance difference of 0.51 mm (range, 0 to 3 mm), with excellent symmetry in 63 (77%) of 82 eyelids on 42 (76%) of 55 patients. There was no significant difference in eyelid symmetry for conjunctival Müllerectomy with or without tarsectomy patients when comparing trainees with staff surgeons ( P = .87).
For the levator advancement surgery subgroup, trainees achieved an average postoperative marginal reflex distance difference of 0.67 mm (range, 0 to 3 mm), with excellent symmetry in 10 (63%) of 16 eyelids of 7 (58%) of 12 patients. The staff surgeon achieved an average postoperative marginal reflex distance difference of 0.67 mm (range, 0 to 2.5 mm), with excellent symmetry in 53 (68%) of 78 eyelids of 36 (65%) of 55 patients. There was no significant difference in eyelid symmetry for levator advancement patients when comparing trainee versus attending surgeons ( P = 1.0). Table 2 summarizes eyelid symmetry results.
| Eyelid Symmetry Results | Average MRD 1 Difference, mm (No. of Patients) | ||
|---|---|---|---|
| Conjunctival Müllerectomy With or Without Tarsectomy | External Levator Advancement | Overall | |
| Preoperative | 1.53 | 1.89 | 1.67 |
| Trainee | 1.71 (48) | 2.17 (12) | 1.80 (60) |
| Staff | 1.37 (55) | 1.83 (55) | 1.60 (110) |
| Postoperative | 0.50 | 0.67 | 0.57 |
| Trainee | 0.49 | 0.67 | 0.53 |
| Excellent | (38) | (7) | (45) |
| Satisfactory | (4) | (3) | (7) |
| Staff | 0.51 | 0.67 | 0.59 |
| Excellent | (42) | (36) | (78) |
| Satisfactory | (8) | (8) | (16) |
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