Eyeworld

EW INTERNATIONAL 122 October 2016 by Stefanie Petrou-Binder, MD, EyeWorld Contributing Writer A primer on the procedure based on discussion from the 2016 German Ophthalmic Surgeons (DOC) meeting T he same techniques for pto- sis surgery have been used for decades, with individual surgeons tweaking and ad- justing the existent meth- ods to optimize surgical comfort and improve outcomes. One aspect of ptosis surgery, however, continues to challenge even the most experienced surgeons: achieving the desired eye contour. This is a more cosmetic as- pect of the surgery and one that has oculoplastic surgeons swearing by whichever particular operative tech- nique allows them to achieve it. This was the subject of a presentation at the 2016 meeting of the German Ophthalmic Surgeons (DOC). Transconjunctival Raman Malhotra, MD, Queen Vic- toria Hospital, East Grinstead, U.K., said he achieves excellent ptosis outcomes that include a natural eye contour using a transconjunctival approach. His minimally invasive, transconjunctival method avoids dissection beyond the conjunctival cut, exposing the undersurface of the levator muscle and simply ad- vancing it. "Transconjunctival is my preferred approach. In the 1980s, the transconjunctival approach was limited to an indication of mild ptosis with good levator function. But with the technique that I have developed, I can do 99% of ptosis, whether it is age related or congeni- tal. The big advantage is that there is predictability of contour—the natu- ral curve of the eyelid," Dr. Malhotra said at the DOC meeting. By contrast, the transcutane- ous approach to ptosis correction involves an anterior cut along the eyelid. The orbital septum and the levator muscle are exposed anteri- orly and the muscle is shortened, thus correcting the droopy lid. According to Dr. Malhotra, "This approach often requires the need for up to three sutures placed at just the right intervals for the eye to resume a natural curve. Even then, the big problem is often what is known as medial droop, which is an unnatural contour. One major advantage of using a transconjunctival approach is the predictability of a nice, natu- ral-looking contour. I think one of the main reasons for this is that you haven't violated all of the anterior structures—you haven't weakened or compromised the orbital sep- tum. I think that the orbital septum provides more of a support for the medial and lateral horns, in partic- ular the medial horn, to maintain a natural curve or contour." Dr. Malhotra, who was trained as a transcutaneous-approach ptosis surgeon, converted to the transcon- junctival approach largely due to the superior contour outcomes. In his experience, ptosis surgery using a transcutaneous approach also has certain benefits. "One advantage of a transcutaneous approach is that it avoids a second incision when you are carrying out a blepharo- plasty. Another advantage is seen in patients with conjunctival scarring diseases or inflammatory diseases of the conjunctiva, as the anterior approach avoids a conjunctival incision. Those are two very import- ant advantages," he said. He went on to explain, "In my opinion, I would do a conjunctival incision even if I were performing a blepharoplasty along with ptosis correction because I would get a more predictable, better contour do- ing ptosis transconjunctivally than if I did it transcutaneously. In terms of lid height/eye symmetry, in my mind it is as good as with the ante- rior approach. But you are avoiding a skin incision, which is another im- portant factor, particularly for young people, where using my technique is preferable," Dr. Malhotra explained. Dr. Malhotra's surgical tech- nique involves everting the eyelid, making a conjunctival incision above the tarsal plate and exposing the levator aponeurosis, represented by a white line, with the post-apo- neurotic fat pad serving as a useful landmark. The aponeurosis is then sutured to the tarsal plate, which effectively shortens the muscle with- out the excision of any tissue. "Success with this method is just under 90%, using the criteria that both eyelids should be 1 mm from each other in terms of height, the contour should be natural, and the skin fold above the eyelid should be natural. Those are the criteria for success that we generally stick to, and based on that, a transconjunc- tival approach using my minimal technique is very successful and reliable. Again, the advantage of the posterior approach is that the con- tour is more natural compared to a transcutaneous approach, although in the hands of a capable surgeon, the transcutaneous approach can achieve good results as well," Dr. Malhotra said. Ongoing debate of two time-tested techniques for ptosis surgery Pre- and post-surgery transconjunctival ptosis approach Source: Raman Malhotra, MD Presentation spotlight

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