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A SIMPLIFIED BLASKOVICS OPERATION FOR BLEPHAROPTOSIS: Results in Ninety-One Operations

A SIMPLIFIED BLASKOVICS OPERATION FOR BLEPHAROPTOSIS: Results in Ninety-One Operations Abstract THE CONSENSUS of ophthalmologists seems to be that resection of the levator is the operation of choice for all cases of blepharoptosis in which the levator muscle is active. Of the 26 operations1 designed to shorten this muscle, the Blaskovics operation seems to be the most popular. Surgeons who prefer to utilize the superior rectus or the frontalis muscle for all types of ptosis as a primary procedure do so because the Blaskovics procedure seems complicated or because no one seems to know just how much levator tissue to excise in each case. The purpose of this article is to present a simplified procedure for shortening the levator palpebrae muscle, to demonstrate what types of ptosis are most suitable for this procedure, and to suggest a simple rule for determining how much levator tissue should be excised in a given case. BLASKOVICS OPERATION FOR RESECTION OF THE LEVATOR PALPEBRAE References 1. Berke, R. N.: Blepharoptosis , Arch. Ophth. 34:434-450 ( (Nov.-Dec.) ) 1945.Crossref 2. de Blaskovics, L.: (a) A New Operation for Ptosis with Shortening of the Levator and Tarsus , Arch. Ophth. 52:563-573 ( (Nov.) ) 1923 3. (b) Treatment of Ptosis: Formation of a Fold in the Eyelid and Resection of the Levator and Tarsus , Arch. Ophth. 1:672-680 ( (June) ) 1929.Crossref 4. Frost, A. D.: Supporting Suture in Ptosis Operations , Am. J. Ophth. 17:633 ( (July) ) 1934. 5. The conjunctiva is so firmly fused to the tarsus that the two structures cannot be separated surgically. The pretarsal tissues, made up of the posterior fascial lining of the orbicularis muscle and the terminal fibers of the levator aponeurosis, are usually reflected surgically with the orbicularis muscle. Therefore, the pretarsal tissue layer is seldom identified as a distinct surgical layer in operations on the upper lid. 6. Whitnall, S. E.: On a Ligament Acting as a Check to the Action of the Levator Palpebrae Superioris Muscle , J. Anat. & Physiol. 45:131, 1911 7. Anatomy of the Human Orbit and Accessory Organs of Vision , Ed. 2, Oxford University Press, 1932. 8. Berke, R. N.: Resection of the Levator Palpebrae for Ptosis with Anatomical Studies , Arch. Ophth. 33:269-280 ( (April) ) 1945. 9. The acquired ptosis followed an operation on the orbit in one case, was associated with neurofibromatosis of the upper lid in one, had developed spontaneously 21 years before in one, followed an injury to the eye in a football game 8 years before in one, developed after ulceration of the cornea 10 years before in one, and followed removal of a benign fibroma of the frontal bone in one. 10. The congenital anomalies were mental retardation, three cases; blepharophimosis, two cases; jaw-winking (Marcus Gunn) phenomenon, two cases; hydrocephalus, one case, and deformities of the heart and spine associated with dwarfism, one case. 11. Five patients had one or more operations utilizing the lifting power of the superior rectus to support the upper lid; 11 had had resections of the levator; 2 had some type of frontalis operation, and 1 had had both a superior rectus and a frontalis type of procedure. 12. There were two cases of blepharophimosis in the former and two cases of the jawwinking (Marcus Gunn) phenomenon in the latter group. 13. If the upper lid moved upward 6 mm. or more without assistance from the frontalis muscle when the patient looked upward from a position of looking down, the levator was considered to have "good" levator action. If it moved only 3 to 5 mm., the action was considered fair, and if the movement was less than 3 mm. it was considered poor. In very young children function was often impossible to grade the amount of elevation present. 14. Many suggestions came from the resident and attending staffs. 15. In 21 private cases the postoperative follow-up notes were gathered from the private records of the physician concerned. 16. The superior rectus suture has been intentionally omitted from the drawings illustrating the steps of the operation. 17. A fine hemostat or an extraocular muscle clamp may be used for this purpose, but neither is entirely satisfactory because the handle of the former gets in the way during the later dissection and because the blades of the latter are too short. 18. If the ptosis is more than 4 mm. or if the levator is very thin, it may be advisable to excise with scissors all but the lower 5 mm. of the tarsus. 19. If sufficient levator tissue has been excised or if the levator muscle is not too delicate, the lid should come up to or above the upper limbus with the eye in the primary position. If not, it is advisable to reinsert the sutures farther back in the levator, to perform a tarsectomy, or to do both. 20. Passing these sutures through the gray line of the upper lid may cause distortion of the lashes, with postoperative irritation of the cornea. 21. In one case in which this complication was not recognized until the end of the operation and the error was not corrected the patient had an overcorrection for several months with a good final result. This complication may account for some of Blaskovics' good results when "the levator [was] absent''.2 22. In cases with weakness of the superior rectus muscle associated with overcorrection, it was sometimes necessary to follow this routine for two to three months; in other cases two to three weeks sufficed. 23. Parenthetically, it should be pointed out in this discussion on the cosmetic correction of ptosis that many of these patients had a disfiguring strabismus as well. It is particularly interesting to note that of the group with normal superior rectus muscles only 7.3% had anomalies of the horizontal extraocular muscle (consisting of one case of incomplete thirdnerve paresis from questionable birth injury, one case of esotropia, and two cases of exotropia), while the other group, with weak superior rectus muscles, had abnormalities of the horizontal extraocular muscle in 66% (consisting of one case third-nerve paresis from questionable birth trauma, five cases of esotropia, five of exotropia, two patients with the jaw-winking phenomenon of Marcus Gunn, and two eyes with complete external ophthalmoplegia with fibrosis of the superior and inferior rectus muscles). These figures illustrate statistically the variable and complicated nature of ptosis and emphasize that the final cosmetic result is governed as much by the nature of the case as by the skill of the surgeon. 24. For example, when the superior rectus was normal only 30.4% of the patients had poor levator action; but when the superior rectus muscle was weak 62.5% of the patients had poor levator action. 25. A pressure dressing was used in almost all of these cases to keep down the edema. 26. Only three lids in this series of 91 operations were higher at the first dressing than they were at the end of operation. 27. Two-0 plain surgical gut sutures lasted 6 to 7 days; 000 plain surgical gut, 5 to 6 days; 0000 plain surgical gut, 4 to 5 days, and 0000 chromic surgical gut, 10 to 12 days. Five-0 plain, 00000 chromic, and 000000 chromic surgical gut sutures were used in a few cases, but were too fragile. Sutures which lasted longer than six days began to slough out and usually had to be removed. 28. Sometimes it was difficult to decide whether the sutures had pulled out or the levator tissue had stretched. 29. In some cases this tissue was measured both when stretched and when relaxed, but generally it was impossible to measure accurately the amount of levator tissue excised, even when relaxed, because of the tendency of the excised levator tissue to roll up on itself. If placed on a block, it could be expanded to almost any size, because when spread lengthwise it became narrow crosswise, and when pulled out crosswise it became shorter lengthwise. Therefore measuring the excised tissue when it was relaxed was no more accurate than estimating the amount of tissue resected when it was stretched. 30. Ever since Wolff (1896) formulated his rule of 1 mm. of levator excision for each millimeter of ptosis. some writers on ptosis have repeated this bit of misinformation. This rule should be discarded because it will nearly always lead to undercorrection, will discredit the operation and will discourage others from trying it. 31. Patients with bilateral ptosis of unequal degree were "problem cases" because if we tried to match the less ptotic eye by doing "just the right amount" of resection undercorrection always resulted. If we resected as much of the levator as possible overcorrection sometimes resulted when the positions of the upper lids were compared. 32. Cusick, P., and Sarrail, J. A.: Blepharoptosis: Modifications of Blaskovics Procedure, Its Indications. Management of Its Complications , Kresge Eye Inst. Bull. 2:38-45 ( (Nov.) ) 1945. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png A.M.A. Archives of Ophthalmology American Medical Association

A SIMPLIFIED BLASKOVICS OPERATION FOR BLEPHAROPTOSIS: Results in Ninety-One Operations

A.M.A. Archives of Ophthalmology , Volume 48 (4) – Oct 1, 1952

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Publisher
American Medical Association
Copyright
Copyright © 1952 American Medical Association. All Rights Reserved.
ISSN
0096-6339
DOI
10.1001/archopht.1952.00920010469011
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Abstract

Abstract THE CONSENSUS of ophthalmologists seems to be that resection of the levator is the operation of choice for all cases of blepharoptosis in which the levator muscle is active. Of the 26 operations1 designed to shorten this muscle, the Blaskovics operation seems to be the most popular. Surgeons who prefer to utilize the superior rectus or the frontalis muscle for all types of ptosis as a primary procedure do so because the Blaskovics procedure seems complicated or because no one seems to know just how much levator tissue to excise in each case. The purpose of this article is to present a simplified procedure for shortening the levator palpebrae muscle, to demonstrate what types of ptosis are most suitable for this procedure, and to suggest a simple rule for determining how much levator tissue should be excised in a given case. BLASKOVICS OPERATION FOR RESECTION OF THE LEVATOR PALPEBRAE References 1. Berke, R. N.: Blepharoptosis , Arch. Ophth. 34:434-450 ( (Nov.-Dec.) ) 1945.Crossref 2. de Blaskovics, L.: (a) A New Operation for Ptosis with Shortening of the Levator and Tarsus , Arch. Ophth. 52:563-573 ( (Nov.) ) 1923 3. (b) Treatment of Ptosis: Formation of a Fold in the Eyelid and Resection of the Levator and Tarsus , Arch. Ophth. 1:672-680 ( (June) ) 1929.Crossref 4. Frost, A. D.: Supporting Suture in Ptosis Operations , Am. J. Ophth. 17:633 ( (July) ) 1934. 5. The conjunctiva is so firmly fused to the tarsus that the two structures cannot be separated surgically. The pretarsal tissues, made up of the posterior fascial lining of the orbicularis muscle and the terminal fibers of the levator aponeurosis, are usually reflected surgically with the orbicularis muscle. Therefore, the pretarsal tissue layer is seldom identified as a distinct surgical layer in operations on the upper lid. 6. Whitnall, S. E.: On a Ligament Acting as a Check to the Action of the Levator Palpebrae Superioris Muscle , J. Anat. & Physiol. 45:131, 1911 7. Anatomy of the Human Orbit and Accessory Organs of Vision , Ed. 2, Oxford University Press, 1932. 8. Berke, R. N.: Resection of the Levator Palpebrae for Ptosis with Anatomical Studies , Arch. Ophth. 33:269-280 ( (April) ) 1945. 9. The acquired ptosis followed an operation on the orbit in one case, was associated with neurofibromatosis of the upper lid in one, had developed spontaneously 21 years before in one, followed an injury to the eye in a football game 8 years before in one, developed after ulceration of the cornea 10 years before in one, and followed removal of a benign fibroma of the frontal bone in one. 10. The congenital anomalies were mental retardation, three cases; blepharophimosis, two cases; jaw-winking (Marcus Gunn) phenomenon, two cases; hydrocephalus, one case, and deformities of the heart and spine associated with dwarfism, one case. 11. Five patients had one or more operations utilizing the lifting power of the superior rectus to support the upper lid; 11 had had resections of the levator; 2 had some type of frontalis operation, and 1 had had both a superior rectus and a frontalis type of procedure. 12. There were two cases of blepharophimosis in the former and two cases of the jawwinking (Marcus Gunn) phenomenon in the latter group. 13. If the upper lid moved upward 6 mm. or more without assistance from the frontalis muscle when the patient looked upward from a position of looking down, the levator was considered to have "good" levator action. If it moved only 3 to 5 mm., the action was considered fair, and if the movement was less than 3 mm. it was considered poor. In very young children function was often impossible to grade the amount of elevation present. 14. Many suggestions came from the resident and attending staffs. 15. In 21 private cases the postoperative follow-up notes were gathered from the private records of the physician concerned. 16. The superior rectus suture has been intentionally omitted from the drawings illustrating the steps of the operation. 17. A fine hemostat or an extraocular muscle clamp may be used for this purpose, but neither is entirely satisfactory because the handle of the former gets in the way during the later dissection and because the blades of the latter are too short. 18. If the ptosis is more than 4 mm. or if the levator is very thin, it may be advisable to excise with scissors all but the lower 5 mm. of the tarsus. 19. If sufficient levator tissue has been excised or if the levator muscle is not too delicate, the lid should come up to or above the upper limbus with the eye in the primary position. If not, it is advisable to reinsert the sutures farther back in the levator, to perform a tarsectomy, or to do both. 20. Passing these sutures through the gray line of the upper lid may cause distortion of the lashes, with postoperative irritation of the cornea. 21. In one case in which this complication was not recognized until the end of the operation and the error was not corrected the patient had an overcorrection for several months with a good final result. This complication may account for some of Blaskovics' good results when "the levator [was] absent''.2 22. In cases with weakness of the superior rectus muscle associated with overcorrection, it was sometimes necessary to follow this routine for two to three months; in other cases two to three weeks sufficed. 23. Parenthetically, it should be pointed out in this discussion on the cosmetic correction of ptosis that many of these patients had a disfiguring strabismus as well. It is particularly interesting to note that of the group with normal superior rectus muscles only 7.3% had anomalies of the horizontal extraocular muscle (consisting of one case of incomplete thirdnerve paresis from questionable birth injury, one case of esotropia, and two cases of exotropia), while the other group, with weak superior rectus muscles, had abnormalities of the horizontal extraocular muscle in 66% (consisting of one case third-nerve paresis from questionable birth trauma, five cases of esotropia, five of exotropia, two patients with the jaw-winking phenomenon of Marcus Gunn, and two eyes with complete external ophthalmoplegia with fibrosis of the superior and inferior rectus muscles). These figures illustrate statistically the variable and complicated nature of ptosis and emphasize that the final cosmetic result is governed as much by the nature of the case as by the skill of the surgeon. 24. For example, when the superior rectus was normal only 30.4% of the patients had poor levator action; but when the superior rectus muscle was weak 62.5% of the patients had poor levator action. 25. A pressure dressing was used in almost all of these cases to keep down the edema. 26. Only three lids in this series of 91 operations were higher at the first dressing than they were at the end of operation. 27. Two-0 plain surgical gut sutures lasted 6 to 7 days; 000 plain surgical gut, 5 to 6 days; 0000 plain surgical gut, 4 to 5 days, and 0000 chromic surgical gut, 10 to 12 days. Five-0 plain, 00000 chromic, and 000000 chromic surgical gut sutures were used in a few cases, but were too fragile. Sutures which lasted longer than six days began to slough out and usually had to be removed. 28. Sometimes it was difficult to decide whether the sutures had pulled out or the levator tissue had stretched. 29. In some cases this tissue was measured both when stretched and when relaxed, but generally it was impossible to measure accurately the amount of levator tissue excised, even when relaxed, because of the tendency of the excised levator tissue to roll up on itself. If placed on a block, it could be expanded to almost any size, because when spread lengthwise it became narrow crosswise, and when pulled out crosswise it became shorter lengthwise. Therefore measuring the excised tissue when it was relaxed was no more accurate than estimating the amount of tissue resected when it was stretched. 30. Ever since Wolff (1896) formulated his rule of 1 mm. of levator excision for each millimeter of ptosis. some writers on ptosis have repeated this bit of misinformation. This rule should be discarded because it will nearly always lead to undercorrection, will discredit the operation and will discourage others from trying it. 31. Patients with bilateral ptosis of unequal degree were "problem cases" because if we tried to match the less ptotic eye by doing "just the right amount" of resection undercorrection always resulted. If we resected as much of the levator as possible overcorrection sometimes resulted when the positions of the upper lids were compared. 32. Cusick, P., and Sarrail, J. A.: Blepharoptosis: Modifications of Blaskovics Procedure, Its Indications. Management of Its Complications , Kresge Eye Inst. Bull. 2:38-45 ( (Nov.) ) 1945.

Journal

A.M.A. Archives of OphthalmologyAmerican Medical Association

Published: Oct 1, 1952

References

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