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 Table of Contents    
Year : 2021  |  Volume : 14  |  Issue : 3  |  Page : 173-178  

Maximal levator resection versus Gore-Tex® sling for congenital blepharoptosis with poor levator function

1 Department of Ophthalmology, The James Cook University Hospital, Middlesbrough, United Kingdom
2 Department of Oculoplastic Surgery, Research Institute of Ophthalmology, Giza, Egypt
3 Department of Ophthalmology, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt

Date of Submission21-Apr-2021
Date of Decision09-Jul-2021
Date of Acceptance18-Jul-2021
Date of Web Publication20-Oct-2021

Correspondence Address:
Dr. Ahmed Said Dawood
Department of Ophthalmology, The James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW
United Kingdom
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ojo.ojo_127_21

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BACKGROUND: Treating congenital blepharoptosis is often mandatory to clear the visual access and avoid amblyopia; however, when the levator function is poor, achieving a satisfactory long-term outcome is challenging. This study aimed to compare the outcomes of maximal levator resection (MLR) with those of frontalis suspension (FS) using Gore-Tex®, in the treatment of congenital blepharoptosis with poor levator function.
PATIENTS AND METHODS: The study included 102 eyelids of 66 patients of mean age 4.3 ± 1.6 standard deviation (SD) years, randomly divided into two groups (51 eyes each). Group A: FS using Gore-Tex®, Group B: MLR. Postoperative outcomes were evaluated at 1, 6 and 12 months. Patients' ophthalmic examination including margin-reflex distance (MRD1) before and after surgery and postoperative complications were recorded.
RESULTS: At the end of the follow-up, the mean MRD1 increased from 0.3 ± 0.7 SD mm in Group A, 0.4 ± 0.8 SD mm in Group B preoperatively, to 2.7 ± 0.5 SD mm and 2.9 ± 0.7 SD mm, respectively (P < 0.001 in both groups). Results of Group B were significantly higher than Group A (P = 0.047). Success was achieved in 77 eyelids (75.4%), distributed as follows: 36 eyelids (70.6%) in Group A, and 41 eyelids (80.1%) in Group B. The total recurrence rate was 6.9% (seven eyes), while other complications were recorded in 23 eyes (22.5%).
CONCLUSION: MLR, compared to FS with Gore-Tex® sling, can be a more efficient surgical option to correct congenital blepharoptosis with poor levator excursion. Prominent postoperative lagophthalmos warrants close ocular surface observation in early follow-up weeks.

Keywords: Congenital ptosis, frontalis suspension, Gore-Tex®, maximal levator resection, poor levator function

How to cite this article:
Dawood AS, Hassan OA, El Sayed MO. Maximal levator resection versus Gore-Tex® sling for congenital blepharoptosis with poor levator function. Oman J Ophthalmol 2021;14:173-8

How to cite this URL:
Dawood AS, Hassan OA, El Sayed MO. Maximal levator resection versus Gore-Tex® sling for congenital blepharoptosis with poor levator function. Oman J Ophthalmol [serial online] 2021 [cited 2023 Mar 26];14:173-8. Available from: https://www.ojoonline.org/text.asp?2021/14/3/173/328597

   Introduction Top

Congenital blepharoptosis mostly results from levator palpebrae superioris (LPS) muscle dysgenesis. Associated visual disturbances may impose early surgery.[1] The crucial measurement in surgery selection is LPS function (considered poor if muscle excursion is four mm or less).[2]

In congenital ptosis with poor levator function, frontalis suspension (FS) has been the treatment of choice. Autologous fascia lata is considered the gold standard sling material; however, it has its limitations such as the patient's age and the need for an additional surgical site which is usually not acceptable to parents. Synthetic alternatives include silicone rods, polypropylene and expanded polytetrafluoroethylene (Gore-Tex®).[3],[4] FS with alloplastic materials may be complicated by brow scars, extrusion, infection, and granuloma.[3] Moreover, absent spontaneous brow elevation can be problematic in unilateral cases and amblyopic eyes with poor fixation.[5]

Other surgeons endorsed maximal levator resection (MLR) as the first-choice surgery. They claimed that MLR could achieve similar outcomes while avoiding FS drawbacks.[6],[7]

Our study compared the outcomes and complications of MLR and FS using Gore-Tex®, in treating congenital blepharoptosis with poor levator function (LF).

   Patients and Methods Top

This prospective study included 102 eyelids of 66 patients (39 males and 27 females), operated on by one surgeon between May 2016 and February 2019. The study was carried out in accordance with the tenets of the Declaration of Helsinki and had approval from the Research Ethical Committee of Faculty of Medicine, Beni-Suef University.

Twenty-eight cases (42.4%) had ptosis in one eye and 38 cases (57.6%) involved both eyes. The mean age was 4.3 ± 1.6 (range 3–8) years.

The patients were randomly assigned to two groups. Group A (51 eyes): Underwent FS (modified Fox pentagon technique – open approach)[8] using Gore-Tex® (W. L. Gore and Associates, Newark, Delaware, USA); and Group B (51 eyes): Underwent MLR. All groups were operated under general anaesthesia. [Table 1] summarizes the characteristics of the study population.
Table 1: Demographic features of the study population

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Patients were eligible if they met all of the following criteria: Congenital ptosis either unilateral or bilateral with poor LPS function (levator excursion ≤4 mm) and no previous surgical ptosis correction.

Operative technique

Frontalis suspension using modified Fox pentagon technique – open approach

All incisions were made using a no. 15 blade. Gore-Tex® was fixed to the tarsus using 5-0 polyester (Ethibond®) sutures, then threaded with a Wright's needle through the forehead incisions.[8] The sling suture was tied so that the lid margin is placed at the level of the upper limbus (the authors adopted the Berke concept to intraoperatively place the ptotic lid above the desired correction level if poor LPS function).[9] Wounds were closed and a Frost 6-0 silk suture was placed to close the palpebral fissure.

Maximal levator resection

After exposure of tarsus, the orbital septum was opened, fat was reflected, then the aponeurosis and Müller's muscle were dissected from the underlying conjunctiva. Both levator horns were carefully severed with the preservation of Whitnall's ligament. The muscle attachments were dissected until the superior orbital margin. A central double-armed 6-0 Vicryl® suture was placed from the tarsal plate (three mm below the superior tarsal border) to exit slightly above Whitnall's ligament. The position of the suture could be adjusted to eventually place the lid at the level of the upper limbus. Then, medial and lateral sutures were inserted to achieve a satisfactory contour and the extra tissue was clamped and excised.[10] Finally, skin closure was done, and a frost suture was placed.

Assessments were performed at 1, 6 and 12 months after surgery. Pre- and post-operative ophthalmic evaluation included: (1) palpebral fissure PF (vertical distance in mm between central upper and lower lid margin with eyes in primary gaze), (2) margin-reflex distance (MRD1) (between the corneal light reflex and the upper lid margin with the eye in the primary gaze; a negative number was given when manual upper lid excursion was needed to reveal a corneal light reflex), (3) LPS function (lid excursion from downgaze to upgaze). PF, MRD1, and LPS function were measured while the frontalis muscle was immobilized at the brow, (4) lagophthalmos (with eyes gently closed), (5) any complications that emerged throughout the follow-up period.

Success was defined as a postoperative MRD1 of three mm or more with a lid symmetry ≤1 mm. Recurrence was defined as a drop in MRD1 below three mm, in a case initially considered as a successful outcome.

Statistical analysis

Statistical analysis was performed using SPSS software V.18.0 (SPSS, Chicago, IL, USA). P <0.05 was considered statistically significant. Fisher's exact test and independent t-test were employed to analyze demographic data. For assessing categorical data, Chi-square (χ2) test was performed. Comparisons of numerical variables between the study groups, and between preoperative and postoperative data at different visits were made using one-way ANOVA.

   Results Top


In total, ptosis correction surgery was done for 102 eyelids of 66 patients with congenital ptosis and poor LPS muscle function. Success was achieved in 77 eyelids (75.4%), distributed as follows: 36 eyelids (70.6%) in Group A, and 41 eyelids (80.1%) in Group B [Figure 1].
Figure 1: Surgical outcomes. Preoperative photographs (a and b), 12 months after right MLR©, and 12 months after left Gore-Tex® sling (D)

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As shown in [Table 2], MRD1 was significantly higher (P < 0.001) in both groups throughout the follow-up duration, when compared to preoperative mean values. The difference between the two groups remained insignificant during the first 6 months, however, at 12 months after surgery, the mean MRD1 of Group B was significantly higher than that in Group A (P = 0.047).
Table 2: Preoperative and postoperative margin-reflex distance 1 measurements (millimetres), for maximal levator resection and frontalis suspension using Gore-Tex®

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By the end of the follow-up period, the overall number of eyes with recurrence was 7 (6.9%). The recurrence rate was higher in Group A, recorded in four eyes (7.8%), followed by Group B in three eyes (5.9%) [Figure 2]. The difference was not statistically significant.
Figure 2: The outcomes of both study groups at 12 months follow-up. MLR: Maximal levator resection

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Lagophthalmos occurred in all cases, nevertheless, its mean values were higher in Group B throughout the follow-up duration [Figure 3]. In regard to sling material related complications in Group A, the rate of postoperative granuloma formation was the highest to be recorded (11.8%).
Figure 3: Progression of lagophthalmos measurements in both groups throughout the study duration. Preop: Preoperative lagophthalmos, MLR: Maximal levator resection, mm: Millimetres

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A summary of all postoperative complications is illustrated in [Table 3].
Table 3: Summary of all postoperative complications in both study groups

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   Discussion Top

In congenital ptosis with poor LF, FS has been the surgical option of choice. Gore-Tex® is a synthetic material, which has the advantage of availability and high reported outcomes.[4]

Other surgeons have embraced MLR, to avoid sling-related complications and achieve better outcomes in unilateral and amblyopic cases, in which a compensatory frontalis action might be absent.[6]

As demonstrated in MLR group results, a success rate (80.1%), with significantly higher mean MRD1 values (P = 0.047) were achieved, compared to the FS group. Besides, the recurrence rate after 1 year was relatively lower to Gore-Tex® (5.9% and 7.8%, respectively).

The main drawback of MLR is, when a large section of LPS is resected, the elastic properties of the lid are markedly impaired, resulting in lid lag and lagophthalmos.[11] Although lagophthalmos was inevitable in all cases, its severity was significantly higher in Group B (P = 0.048) after 1 month. The previous data correlated with the potential risk of exposure to keratopathy. It has been observed that sequelae of exposure keratopathy were reported at the first 2 follow-up months. To minimize this, we recommend that a frost suture is placed at the conclusion of surgery for 48 h, followed by frequent lubrication for at least 8 weeks along with eye ointment and lid taping at sleep time for the first 2 weeks. Parents' awareness of possible hazards through preoperative education is invaluable to ensure compliance with given postoperative instructions, treatment, and follow-up appointments. The authors believe that eyes with poor Bell's phenomenon are not suitable for MLR.

Postoperative configuration of lashes and lid margin could resemble another drawback. After resection, the imbalance between the excess tension on the tarsus and the relatively loose anterior lamella can lead to lash ptosis and lid margin inward rotation.[11] In Group B, these complications occurred in nearly one-fifth of the operated lids. Lash ptosis has shown spontaneous improvement-partial or complete-over time; while marginal inversion required anterior lamellar repositioning surgery. We found that the downward slide of lashes could be avoided by excising a segment of skin and orbicularis above the crease then suturing both incision lips (more importantly the pretarsal flap) to the resected LPS at the end of the procedure, or to the tarsal plate instead.[6] Twelve of the MLR treated eyes had this additional step, with no postoperative lash ptosis recorded (P = 0.092).

Many reports were published on MLR in congenital ptosis; however, to our knowledge, there is only one prior comparison between MLR and FS in the case of poor LF, where autogenous fascia lata (AFL) and preserved fascia lata (PFL) were used.[12] Results released have been consistent with our study outcomes. The MLR group had parallel mean postoperative MRD1 to AFL while greater than PFL, and significantly higher mean postoperative lagophthalmos compared to overall FS surgery. The authors concluded that MLR is an alternative to FS in congenital ptosis patients with poor LF, with the risk of postoperative lagophthalmos related to higher postoperative MRD1.[12]

Of note, some studies compared the outcomes of FS to levator resection (LR) in congenital ptosis repair, however, LR was used when LF was more than 4 mm.[13],[14] Since LF determines the amount of resection, the difference in the number of mm resected between LR in good function and MLR in poor function would result in different success and complications rates. Consequently, comparing these studies' outcomes to ours was not applicable.

Epstein and Putterman,[10] Mauriello et al.,[15] and Press and Hübner,[16] have achieved more than 75% satisfactory outcomes with MLR in correcting congenital ptosis with poor LF.

Cruz et al.,[11] Mete et al.,[17] and Lee et al.[18] have also published about the use of MLR in congenital ptosis. A significant increase (P < 0.05) in postoperative MRD1 was observed in all studies, and successful results were obtained in 91.4%, 69.6% and 93.0% respectively. Reported complications varied between abnormal spontaneous blinks (93%), lash ptosis (31.4%), and exposure keratopathy (11.1%).

As regarding FS, Gore-Tex® is proved to be inert, both chemically and biologically.[19] Our results have shown that it might be inferior to MLR for long-term lid elevation. In addition, Gore-Tex® had a high incidence of developing soft tissue complications, particularly postoperative granuloma (11.8%). All these cases responded well to granuloma excision and multilayer wound closure, together with local subcutaneous antibiotic injection, without the need for sling explanation.

Reviewing literature has provided variable results. Gore-Tex® is considered by many surgeons as an effective alloplastic material for FS, with a recurrence rate ranging from 0% to 15%,[20],[21],[22],[23] that correspond to our results (7.8%). It is believed that tissue scarring is strong enough to maintain adequate eyelid height even if Gore-Tex® itself is removed.[24] However, its porous configuration may promote bacterial proliferation,[19] resulting in infection or granuloma formation, for which Gore-Tex® shows the highest rate among other materials.[13],[24] In general, the introduction of a suspensory material might significantly raise the complications rate in FS compared to LR in congenital ptosis repair.[13]

Finally, some authors used frontalis muscle flap (FMF) as an alternative to FS and compared its outcomes to those of MLR in congenital ptosis with poor LF. They said FMF can give satisfactory ptosis correction and dynamic location of both eyelid and brow. The outcomes were approximately similar to MLR, and FMF showed more stability on long-term follow-up. Nevertheless, it has been found that FMF may cause more examples of aesthetic and functional complications, which can be reduced with MLR.[25],[26]

   Conclusion Top

Our results demonstrate that, compared to FS using Gore-Tex®, MLR could be a better surgical option to correct congenital blepharoptosis with poor levator excursion, whether unilateral or bilateral. As postoperative lagophthalmos is prominent, the authors recommend careful ocular surface monitoring in the early follow-up weeks.

Limitations of the study

Taking into consideration the young age of the study population, the authors recommend a similar comparison with a longer follow-up period to further evaluate the stability of outcomes.

Declaration of patient consent

The authors certify that they have obtained the appropriate informed consent from parents/guardians of children enrolled in the study, including acceptance of the surgery, purpose, potential complications and the possible adjustment or reoperation according to postoperative result. In addition, parents of patients shown in [Figure 1] have given consent for the images to be used in published media

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]


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