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 Table of Contents  
Year : 2020  |  Volume : 21  |  Issue : 3  |  Page : 223-227

Transconjunctival levator muscle plication in mild to moderate congenital ptosis

Department of Ophthalmology, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission23-Mar-2020
Date of Decision08-May-2020
Date of Acceptance31-May-2020
Date of Web Publication23-Sep-2020

Correspondence Address:
MSC Reem A.K Dessouky
Faculty of Medicine, Zagazig University, Koliat Al Tob Street, Zagazig 44519
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/DJO.DJO_26_20

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Purpose The aim of this study was to evaluate the efficacy, cosmetic result, and safety of transconjunctival plication of the levator muscle in the correction of simple congenital ptosis.
Patients and methods This is a prospective interventional study that was performed on 23 eyelids (17 unilateral and three bilateral) of 20 patients with simple congenital ptosis and fair to good levator muscle function. All patients were subjected to transconjunctival levator plication. Preoperative history taking and ophthalmological examination were performed. Degree of ptosis was evaluated using the marginal reflex distance 1 (MRD1). Levator muscle function was evaluated using the Berke’s method. Serial follow-up was performed for all patients.
Results The mean age of the patients was 6.65±3.13 years. Anatomical success (MRD1 of 3–5 mm and intereyelid difference of <1 mm) was achieved in 20 (86.96%) eyelids, whereas undercorrection occurred in three (13.04%) eyelids. A good cosmetic outcome was obtained in 21 (91.3%) eyelids. A statistically significant improvement was found between the preoperative MRD1 values and the 1- and 6-month postoperative values (P<0.001). There was no significant difference between MRD1 at 1 and 6 months, postoperatively (P=0.07). No major postoperative complications were reported.
Conclusion Levator plication using the posterior transconjunctival approach is safe and effective for correcting simple congenital blepharoptosis with a good cosmetic outcome. This technique is especially useful for mild and moderate cases of congenital ptosis associated with good to fair levator muscle function.

Keywords: congenital, levator, plication, ptosis

How to cite this article:
Abdel Fattah ME, Basiony OE, Saleh ME, Dessouky RA. Transconjunctival levator muscle plication in mild to moderate congenital ptosis. Delta J Ophthalmol 2020;21:223-7

How to cite this URL:
Abdel Fattah ME, Basiony OE, Saleh ME, Dessouky RA. Transconjunctival levator muscle plication in mild to moderate congenital ptosis. Delta J Ophthalmol [serial online] 2020 [cited 2022 Aug 18];21:223-7. Available from: http://www.djo.eg.net/text.asp?2020/21/3/223/295880

  Introduction Top

Congenital ptosis is a common and challenging oculoplastic problem. Various surgical techniques have been described to correct it. The chosen procedure is mainly based on the ptosis severity and levator function [1]. Levator resection or plication are preferred for congenital ptosis with at least 5 mm of levator action [2]. Levator plication is a simple and fast procedure. It requires less dissection and preserves the anatomy and physiology of the muscle [3]. The transconjunctival approach is associated with rapid healing and no cutaneous scars [4],[5].

The aim of this study was to evaluate the outcome of transconjunctival levator muscle plication in mild to moderate congenital blepharoptosis.

  Patients and methods Top

This prospective, interventional study was performed over a 2-year period (August 2017 to September 2019) after receiving the Institutional Review Board (IRB) and Ethical Committee of Faculty of Medicine, Zagazig University, approval. All patients were subjected to transconjunctival levator plication as a treatment for their congenital ptosis after their legal guardians signed a written informed consent to participate in the study and for publication of data.

Inclusion criteria were patients with mild to moderate simple congenital ptosis and good to fair levator muscle function. Exclusion criteria were severe ptosis, poor levator action, poor Bell’s phenomenon, lagophthalmos, diminished corneal sensation, complicated congenital or acquired ptosis, or history of previous lid surgery.

General physical examination to rule out any acquired cause and to assess the fitness for surgery and general anesthesia was performed. Detailed history, including time of onset and progression of ptosis, diurnal variation, change in ptosis upon eating and swallowing, associated eye deviation, and any previous eye or other surgery, was taken. Complete ocular examination was performed with special attention to corneal sensation, Bell’s phenomenon, orbicularis muscle function, and the presence of lagophthalmos. Ptosis was evaluated by measuring the marginal reflex distance 1 (MRD1) and the levator muscle excursion (using the Berke’s method) [6]. The degree of ptosis was graded according to the amount of lid drooping as mild (<2 mm), moderate (2–4 mm), and severe (>4 mm). Levator function was graded according to the eyelid excursion as excellent (≥13 mm), good (8–12 mm), fair (5–7 mm), and poor (≤4 mm).

Surgical technique

All surgeries were performed under general anesthesia by the same ophthalmic surgeon (R.A.K.D.) using the same surgical technique. The surgical site and eye lashes were cleaned with 50 g/l povidone iodine (Betadine; El-Nile Co. for Pharmaceuticals and Chemical Industries, Cairo, Egypt), and a sterile drape was put in place. A 3-0 silk traction suture was placed at the eyelid margin, and the upper lid was everted over a Desmarres retractor. Overall, 0.5 ml of lidocaine 2% (Sigma-Tec Pharmaceutical Indust. Co., 6th of October City, Egypt) with 1 : 100 000 adrenaline (Chemical Industries Development ‘CID,’ Giza, Egypt) was injected subconjunctivally.

The conjunctiva was cut along the superior margin of the tarsus, and the Muller’s muscle and conjunctiva were separated as a composite flap. Dissection continued at the plane between the posterior surface of the levator aponeurosis and the Muller’s muscle-conjunctival flap. Then, one to three cutaneous stab incisions were made at the desired level of the skin crease, and 5-0 vicryl sutures were used to plicate the levator muscle. Each suture passed vertically through the skin incision and the superior border of the tarsal plate and then horizontally through the posterior surface of the levator at the level that achieved the desired amount of plication. The suture was completed by exiting through the upper tarsal border and the skin incision again 2 mm apart from its entrance. The sutures were tied in a slip knot to assess their effectiveness before tying into a permanent knot. The Muller’s muscle and conjunctiva were left to heal spontaneously with no excision or suturing of these structures. The absorbable sutures were not removed postoperatively ([Figure 1]a–h).
Figure 1 Surgical procedure. (a) Subconjunctival injection of a mixture of lidocaine and adrenaline. (b) Dissection between the levator and Muller’s muscle. (c) Stab incision at the skin crease. (d) 5-0 vicryl suture passing vertically through the skin incision. (e) A caliper measuring the amount to be plicated. (f) Suture passing horizontally through the levator at the level of plication. (g) Suture passing through the upper tarsus to exit through the stab incision. (h) Temporary knot to assess the efficacy of the suture.

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The amount of plication was calculated as 3 mm for every 1 mm of ptosis in cases with good levator function and 4 mm for every 1 mm of ptosis in cases with fair levator function. Intraoperative eyelid level in relation to the limbus was also used as a guide for adjustment of the ptosis correction. The upper eyelid margin was set to rest 1 mm below the limbus in cases with good levator function and at the limbus in cases with fair levator function.

Tobramycin 0.3% ointment was applied onto the skin at the site of the stab incisions and into the conjunctival sac. All patients were prescribed lubricant eye drops every hour [Cornetears (vitamin A palmitate 1000 IU); Orchidia Pharmaceutical Industries, Al-Obour City, Egypt], moxifloxacin 0.5% eye drops four times daily (Fortymox; Orchidia Pharmaceutical Industries), and tobramycin 0.3% eye ointment at bed time (Tobrin; EIPICO, Cairo, Egypt). A systemic antibiotic was administered for 1 week. Follow-up examinations were carried out at the first day, first week, first month, and sixth month, postoperatively. Postoperative assessment was performed at day 1 and week 1 to detect and treat any immediate postoperative complications. Anatomical and cosmetic outcome was assessed at 1 and 6 months postoperatively to allow for more accurate measurements following the amelioration of the postoperative edema. Anatomical success was defined as MRD1 of 3–5 mm and an inter-lid difference less than 1 mm. Cosmetic outcome was assessed regarding lid contour and lid crease.

Statistical analysis

Patient demographics, preoperative and postoperative clinical examination findings, ptosis grade, and follow-up data were collected. Descriptive statistics were used to summarize demographic and clinical data. Paired t test was used to compare between preoperative and postoperative MRD1. t test was used to compare between MRD1 at 1 and 6 months, postoperatively. All statistical analyses were performed using the statistical package for social science (SPSS statistics version 25; IBM, Armonk, New York, USA) using a 95% confidence interval. P value less than 0.05 was considered statistically significant.

  Results Top

A total of 20 patients (23 eyelids) were included in the study. The age of the patients ranged from 4 to 16 years (mean: 6.65±3.13 years), with a male to female ratio of 3 : 1. Overall, 17 (85%) patients had unilateral ptosis and three (15%) patients had bilateral ptosis. [Table 1] demonstrates the frequency distribution of the baseline population characteristics.
Table 1 Baseline population characteristics

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The preoperative degree of ptosis was mild in 9/23 (39%) eyelids and moderate in 14/23 (61%) eyelids ([Table 1]). The mean preoperative levator function and MRD1 values were 8.52±1.41 mm (range, 6–11 mm) and 1.72±0.58 mm (range, 1–2.5 mm), respectively ([Figure 3]a and [Figure 4]a).

The mean operative time was 11.61±1.47 min. No intraoperative complications were reported.

No major postoperative complications (such as exposure keratitis, corneal abrasion, or entropion) were reported. Minor complications developed among four (20%) patients. Nocturnal lagophthalmos occurred in three cases and completely resolved within 1 month without any sequelae. One case developed conjunctival prolapse at the first week that resolved with medical treatment.

At 1 and 6 months postoperatively, the anatomic assessment showed a mean postoperative MRD1 values of 3.30±0.89 and 3.80±0.89 mm, respectively. A statistically significant improvement was found between the preoperative and postoperative MRD1 values at 1 month (P<0.001) and 6 months (P<0.001) ([Table 2], [Figure 2]). No statistically significant difference was found between the MRD1 values at 1 and 6 months, postoperatively (P=0.07). Anatomical success was achieved in 20 (86.96%) eyelids ([Figure 3]b and [Figure 4]b), while undercorrection occurred in three (13.04%) eyelids ([Figure 5]). Only one patient with undercorrection was dissatisfied and underwent a second operation via a skin approach with a good outcome. At 1 month postoperatively, the cosmetic assessment showed an asymmetric lid crease in one patient and a temporal flare in another patient. At 6 months, these findings persisted in the same patients without improvement. However, no intervention was required as both patients were satisfied with the operative outcome and refused further corrective surgery. Cosmetic outcome was satisfactory in 21 (91.3%) eyelids. Only two (8.70%) patients had a suboptimal outcome ([Figure 5]).
Table 2 Preoperative and postoperative marginal reflex distance 1

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Figure 2 Changes in mean MRD1 in each follow-up. MRD1, marginal reflex distance 1.

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Figure 3 A 7-year-old girl presenting with right moderate ptosis and a good levator function. (a) MRD1 was 1.5 mm and levator function was 8 mm. (b) Six months after surgery, MRD1 is 4 mm, and there is a satisfactory cosmetic outcome. MRD1, marginal reflex distance 1.

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Figure 4 A 5-year-old boy with right moderate ptosis and fair levator action. (a) Preoperative MRD1 was 1 mm and levator function was 7 mm. (b) Postoperative MRD1 improved to 3.5 mm, and there is a good lid crease and contour. MRD1, marginal reflex distance 1.

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Figure 5 Anatomical and cosmetic success at the last follow-up visit.

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  Discussion Top

Levator plication or levator tuck is a modification of the advancement procedure that was first introduced for treatment of involutional ptosis by Jones et al. [7] and was then extended to be used in congenital ptosis by Harris and Dortzbach [8] using a cutaneous approach. Over the years, it was proven successful, with several surgeons reporting favorable outcomes [3],[9],[10]. Most studies on congenital ptosis have shown good results with levator plication via a cutaneous approach [11],[12],[13]. However, only few studies have implemented the conjunctival approach for levator plication in congenital ptosis [5],[14]. In an aim to fill this gap in literature, we evaluated the safety and efficacy of transconjunctival levator muscle plication in the management of mild to moderate simple congenital blepharoptosis.

In the current study, satisfactory correction was obtained in 20 eyelids and undercorrection was obtained in three of 23 eyelids (86.96 and 13.04%, respectively). No serious complications (exposure keratitis, corneal abrasion, or entropion) occurred throughout the study period. These results agreed with Al-Abbadi et al. [14] and Abdelkader and Abdallah [15] who reported a success rate of 87 and 86.7%, respectively, using a similar technique and with the study by Abdelbaky et al. [16], in which the results of two-point fixation levator aponeurosis tuck and the standard levator resection were compared. In the latter study, a surgical success rate of 85.7% was reported for levator tucking at 3 months postoperatively. Higher success rates were found by Hong et al. [12], who described a novel ‘under–through levator complex plication method’ in patients with mild to moderate congenital ptosis and a levator function greater than 5 mm. They reported a success rate of 94.5%, which they attributed to the modification they applied to the plication technique. Fixing the two structures en-bloc onto the tarsus produced more permanent adhesions and avoided cheese wiring at the site of fixation.Furthermore, the cosmetic result, in the present study, was satisfactory in 21 (91.3%) eyelids. In Hussain [11] study, which assessed the cosmetic result of levator aponeurosis tuck in patients with congenital ptosis, a satisfactory outcome was obtained in 90% of the patients, which is similar to the findings of the current study.

The limitations of this study include the small sample size and a relatively short-term follow-up. Future large-scale studies with longer follow-up durations are needed to establish the long-term outcome of this technique.

  Conclusion Top

The transconjunctival levator plication is an effective technique in the treatment of mild to moderate congenital ptosis with good to fair levator muscle action. It is a relatively quick and easy procedure. Satisfactory anatomical and cosmetic results can be obtained by this procedure without significant complications.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Kumar S, Kamal S, Kohli V. Levator plication versus resection in congenital ptosis − a prospective comparative study. Orbit 2010; 29:29–34.  Back to cited text no. 1
Chung S, Ahn B, Yang W, Bum J, Kim K, Kang S. Borderline to moderate blepharoptosis correction using retrotarsal tucking of müller muscle: levator aponeurosis in Asian eyelids. Aesthetic Plast Surg 2015; 39:17–24.  Back to cited text no. 2
Burman S, Betharia SM, Bajaj MS. Orbit oculoplasty. In: AIOC Proceedings. 2002, p. 1:441.  Back to cited text no. 3
Leatherbarrow B. Blepharoptosis. In: Brian Leatherbarrow Oculoplastic surgery. 2nd revised ed. London, United Kingdom: Informa Healthcare; 2010. 159–162.  Back to cited text no. 4
Bajaj MS, Pushker N, Mahindrakar A, Balasubramanya R. Advancement of Whitnall’s ligament via the conjunctival approach for correction of congenital ptosis. Orbit 2004; 23:153–159.  Back to cited text no. 5
Berke RN. Blepharoptosis. Arch Ophthalmol 1945; 34:434–450.  Back to cited text no. 6
Jones LT, Quickert MH, Wobig JL. The cure of ptosis by aponeurotic repair. Arch Ophthalmol 1975; 93:629–634.  Back to cited text no. 7
Harris WA, Dortzbach RK. Levator tuck: a simplified blepharoptosis procedure. Ann Ophthalmol 1975; 7:873–878.  Back to cited text no. 8
Older JJ. Levator aponeurosis surgery for the correction of acquired ptosis: analysis of 113 procedures. Ophthalmology 1983; 90:1056–1059.  Back to cited text no. 9
Liu D. Ptosis repair by single suture aponeurotic tuck: surgical technique and long-term results. Ophthalmology 1993; 100:251–259.  Back to cited text no. 10
Hussain I. Cosmetic outcome of three sutures levator aponeurosis tuck procedure in congenital ptosis. J Coll Physicians Surg Pak 2006; 16:652–654.  Back to cited text no. 11
Hong SP, Song SY, Cho IC. Under-through levator complex plication for correction of mild to moderate congenital ptosis. Ophthal Plast Reconstr Surg 2014; 30:468–472.  Back to cited text no. 12
Wang C, Wang Y. Comparison of surgical efficacy of levator muscle shortening and modified levator aponeurosis tucking in treat- ing minimal and moderate congenital blepharoptosis. Eye Sci 2015; 30:29–30.  Back to cited text no. 13
Al-Abbadi Z, Sagili S, Malhotra R. Outcomes of posterior-approach ‘levatorpexy’ in congenital ptosis repair. Br J Ophthalmol 2014; 98:1686–1690.  Back to cited text no. 14
Abdelkader M, Abdallah R. Evaluation of transconjunctival levator tucking for congenital ptosis. J Egypt Ophthalmol Soc 2017; 110:41.  Back to cited text no. 15
  [Full text]  
Abdelbaky SH, Elessawy RA, Hassanein DH, Abdelrahman KB, Mohamed HH. Two-point fixation levator aponeurosis tucking versus standard levator resection for congenital blepharoptosis. J Am Assoc Pediatr Ophthalmol Strabismus 2018; 22:e8–e9.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2]


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