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Figure 1. Clinical photographs of patients with congenital ptosis (A, C, E, and G). Lower eyelid elevation and disappearance of scleral show were noted after surgery (B, D, and F) and upper eyelid lift (H). The levels of the pupillary light reflex (a), medial canthus (b), and lower eyelid margin (c) are shown (G and H).

Figure 1. Clinical photographs of patients with congenital ptosis (A, C, E, and G). Lower eyelid elevation and disappearance of scleral show were noted after surgery (B, D, and F) and upper eyelid lift (H). The levels of the pupillary light reflex (a), medial canthus (b), and lower eyelid margin (c) are shown (G and H).

Figure 2. The line between the medial and lateral canthi (LML) and the maximal perpendicular distance from the LML to the margin of the lower eyelid (PDL) are noted. The preoperative lower scleral show in both eyes (A) disappeared postoperatively (B).

Figure 2. The line between the medial and lateral canthi (LML) and the maximal perpendicular distance from the LML to the margin of the lower eyelid (PDL) are noted. The preoperative lower scleral show in both eyes (A) disappeared postoperatively (B).

Table. Patients' Characteristics and Postoperative Positional Changes of the Lower Eyelid According to the Type of Surgery in Congenital Ptosis
Table. Patients' Characteristics and Postoperative Positional Changes of the Lower Eyelid According to the Type of Surgery in Congenital Ptosis
1.
Matsuo K, Kondoh S, Kitazawa T, Ishigaki Y, Kikuchi N. Pathogenesis and surgical correction of dynamic lower scleral show as a sign of disinsertion of the levator aponeurosis from the tarsus.  Br J Plast Surg. 2005;58(5):668-675PubMedArticle
2.
Sultana R, Matsuo K, Yuzuriha S, Kushima H. Disinsertion of the levator aponeurosis from the tarsus in growing children.  Plast Reconstr Surg. 2000;106(3):563-570PubMed
3.
Dortzbach RK, Gausas RA, Sherman DD. Blepharoptosis. In: Dortzbach RK, ed. Ophthalmic Plastic Surgery: Prevention and Management of Complications. New York, NY: Raven; 1994:76
4.
Iliff JW, Pacheco EM. Ptosis surgery. In: Tasman W, Jaeger EA, eds. Duane's Clinical Ophthalmology. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:1-18
5.
Cruz AA, Lucchezi MC. Quantification of palpebral fissure shape in severe congenital blepharoptosis.  Ophthal Plast Reconstr Surg. 1999;15(4):232-235PubMedArticle
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Research Letters
Surgeon's Corner
April 2013

Positional Change of Lower Eyelid After Surgical Correction of Congenital Ptosis in the Korean Population

Author Affiliations

Author Affiliations: Department of Ophthalmology, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea (Drs Kim, Yoon, and Lee); and Department of Ophthalmology, The Third Hospital of Peking University, Beijing (Dr Zhao), and Department of Ophthalmology, Affiliated Hospital, Yanbian University Medical College, Jilin (Dr Wu), China.

JAMA Ophthalmol. 2013;131(4):540-542. doi:10.1001/jamaophthalmol.2013.2825

SURGEON'S CORNER

We have found that some patients with congenital ptosis have preoperative lower scleral show that is diminished after ptosis surgery (Figure 1). This quantitative study investigates the positional change in the lower eyelid after surgery to correct congenital ptosis.

Methods

The local institutional review board approved this study. Written informed consent was obtained from all the participants, including parents or legal guardians.

Medical records and clinical photographs of 55 Korean patients with congenital ptosis who underwent corrective surgery were reviewed. Patients with the following conditions were excluded: neuromuscular diseases, blepharophimosis, strabismus, previous and concomitant eyelid surgery, and less than 6 months of follow-up.

The position of the lower eyelid was assessed by the maximal perpendicular distance (PDL) from the line between the medial and lateral canthi to the margin of the lower eyelid (Figure 2) and by the relative location (RLL) defined as the ratio of the PDL to the length of the line between the medial and lateral canthi. It was not assessed by the margin reflex distance 2 because it may easily vary with gaze, it can be inaccurately measured in young children, and the drooped upper eyelid often obscures the pupillary light reflex. The PDL and RLL of each eye were compared before and 6 months after surgery.

Results

Lower scleral show was found in 7 ptotic eyes (8.9%) preoperatively and disappeared in all but 1 eye postoperatively. Patient characteristics and postoperative changes in the PDL and RLL are shown in the Table.

The PDL and RLL significantly decreased 6 months after surgery in the frontalis suspension group (P < .001 for both). They showed significant decrease in some bilateral ptosis cases (P < .001 for both in bilateral frontalis suspension surgery, P = .09 for change in PDL and P = .11 for change in RLL in the eye with frontalis suspension surgery in patients who underwent frontalis suspension in one eye and levator resection in the other) but not in unilateral cases.

Comment

More than 80% of cases with preoperative lower scleral show improved after surgery. In the frontalis suspension group, the PDL and RLL decreased significantly 6 months after surgery, indicating postoperative lower eyelid elevation.

One possible mechanism for these results is the compensatory contraction of the lower eyelid retractor for drooped upper eyelid as suggested by Matsuo et al1 and Sultana et al,2 who demonstrated excessive contraction of the levator muscle in aponeurotic ptosis.1,2 In congenital ptosis, there could also be excessive contraction of the levator muscle followed by compensatory contraction of the lower eyelid retractor and postoperative release.

Postoperative change in the lower eyelid position was significant in bilateral ptosis compared with unilateral ptosis. The compensatory contraction would be more pronounced in bilateral ptosis because patients with unilateral ptosis can see well in the nonptotic eye and do not have the stimulation to lift the ptotic eyelid.3

However, the influence of compensatory contraction of the levator–lower eyelid retractor may be limited in congenital ptosis because of improper or faulty development of the levator muscle.4 Another possible mechanism is the mechanical effect of upper eyelid lift during ptosis surgery. Upper eyelid lift can lead to lower eyelid elevation due to the circumferential structure of the orbicularis muscle and changeability of the canthi position.5

These 2 mechanisms may be operative at the same time. Compensatory contraction may be stronger in patients with poorer levator function, and the larger amount of intraoperative upper eyelid lift may result in greater elevation of the lower eyelid.

In conclusion, this study shows lower eyelid elevation after surgical correction of congenital ptosis, especially after frontalis suspension or in bilateral ptosis. Surgeons should inform patients that lower eyelids can displace upward after ptosis surgery and that preoperative lower scleral show can be diminished postoperatively.

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Article Information

Correspondence: Dr Lee, Department of Ophthalmology, Institute of Vision Research, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea (sylee@yuhs.ac).

Published Online: February 21, 2013. doi:10.1001/jamaophthalmol.2013.2825

Author Contributions: Dr Lee had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Conflict of Interest Disclosures: None reported.

Previous Presentation: This paper was presented as a poster at the 2011 Annual Meeting of the American Academy of Ophthalmology; October 22-25, 2011; Orlando, Florida.

References
1.
Matsuo K, Kondoh S, Kitazawa T, Ishigaki Y, Kikuchi N. Pathogenesis and surgical correction of dynamic lower scleral show as a sign of disinsertion of the levator aponeurosis from the tarsus.  Br J Plast Surg. 2005;58(5):668-675PubMedArticle
2.
Sultana R, Matsuo K, Yuzuriha S, Kushima H. Disinsertion of the levator aponeurosis from the tarsus in growing children.  Plast Reconstr Surg. 2000;106(3):563-570PubMed
3.
Dortzbach RK, Gausas RA, Sherman DD. Blepharoptosis. In: Dortzbach RK, ed. Ophthalmic Plastic Surgery: Prevention and Management of Complications. New York, NY: Raven; 1994:76
4.
Iliff JW, Pacheco EM. Ptosis surgery. In: Tasman W, Jaeger EA, eds. Duane's Clinical Ophthalmology. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:1-18
5.
Cruz AA, Lucchezi MC. Quantification of palpebral fissure shape in severe congenital blepharoptosis.  Ophthal Plast Reconstr Surg. 1999;15(4):232-235PubMedArticle
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