Pediatric Ptosis Repair: Muller Muscle Conjunctival Resection
Paramjit K. Bhullar, MD
Jason A. Liss, MD
PREOPERATIVE CONSIDERATIONS
Select Appropriate Patients
Muller muscle conjunctival resection is uncommonly performed in children.
Procedure advantages:
Can be done under local or general anesthesia, a distinct advantage in the pediatric population.
There is no visible skin scar.
Candidates should meet the following criteria:
Have between 1 and 2.5 mm ptosis.
Have a 1.5-mm improvement in ptosis with phenylephrine testing (ie, 5 minutes after placing 1 drop of phenylephrine 2.5% onto the ptotic eye).
Have greater than 10 mm levator function.
Have a defined lid crease.
A less than 1.5-mm improvement in ptosis with phenylephrine testing may be acceptable in some cases; that is, if it places the eyelid in a position that the patient would consider an improvement.
Patients with congenital ptosis may not have a defined lid crease and would be suboptimal candidates for Muller muscle conjunctival resection, as they would require a separate procedure to create an eyelid crease.
Preoperative Documentation
Record the distance between the upper eyelid margin and the corneal light reflex (MRD1) and consider photos before and after phenylephrine testing.
Record levator function.
Determine the amount of tissue to be resected.
Numerous nomograms and strategies exist for the amount of tissue to be resected, based the on degree of ptosis; a commonly used strategy is to resect 4 mm of conjunctiva per 1 mm of desired ptosis correction.
Preoperative Counseling
In addition to usual surgical risks, patients should be counseled on the following:
Foreign body sensation until suture dissolution.
Undercorrection or overcorrection of ptosis, with need for revision ˜15% of the time.
SURGICAL PROCEDURE
Ensure that the OR has a Putterman clamp.
If the patient allows, mark the skin of the upper eyelid margin corresponding to the pupillary position while the patient is in primary gaze.
Evert the eyelid and inject lidocaine 2% with 1:100,000 epinephrine and 200 USP units hyaluronidase per 20 cc anesthetic, into the conjunctiva, superior to the tarsal plate. Alternatively, local anesthetic may be injected inferior to the brow, with the eyelid in normal position.
Prep and drape the patient in a sterile fashion.
Place a 4-0 silk suture through the upper eyelid margin, at the level of the tarsus (Fig. 40.1).
Evert the upper eyelid over a Desmarres retractor (Fig. 40.2).
Use calipers to measure half the desired resection of conjunctiva superior to the superior border of the tarsus, and mark this distance centrally, medially, and laterally. Note: Allow for at least 5 mm of space between the central mark and the medial mark, as well as between the central mark and lateral mark (Fig. 40.3).
Use forceps to lift conjunctiva and Muller muscle (it will naturally separate from the underlying levator muscle), place a 6-0 nylon traction suture through each of the three marked areas, and pull up on these traction sutures to elevate the tissue to be clamped and resected (Fig. 40.4).
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