Lecture: Congenital Ptosis: Diagnosis and Management
During this Live Lecture, the evaluation and treatment of the child with ptosis will be discussed. Surgical videos detailing Mueller Muscle resection, lever resection with modified tarsal resection and small incision frontalis sling will be shown.
Lecturer: Dr. Andrew Harrison, Associate Professor & Director of Oculoplastic and Orbital Surgery at the University of Minnesota Medical School, USA
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DR HARRISON: Hello, and welcome. I’m Dr. Andrew Harrison. I’m an oculoplastic surgeon at the University of Minnesota. And I’m really happy to have everybody here tonight at the Cybersight lecture. And today I’m gonna talk about congenital ptosis. And congenital ptosis is something near and dear to my heart. I think it’s one of the most difficult things that we deal with as ophthalmologists who do ptosis surgeries. Specifically, I guess, oculoplastic surgeons. So let’s dive in. And I guess I like this quote by Richard Dortzbach, from University of Wisconsin, who said: Ptosis is hell. And I would add: Congenital ptosis is double hell. It’s really, really difficult to deal with. And I appreciate you listening to the lecture tonight. And just to let you know, you can send questions to me, as we go. And I can answer those at the end. So I would be happy to do that for you. So here’s the outline of the talk. And I know Bob Kersten, who is a good friend of mine, recently gave two great Cybersight lectures on congenital ptosis. I’m sorry, on ptosis. And I really didn’t want to cover the same things that Bob’s covered, so I really want to focus on my surgical approaches. And I have some videos in here, I think, that’ll really help with that. But we’ll also talk a little bit about clinical evaluation, the differential diagnosis, and then we’ll get into some of these surgical approaches. So first of all, I have a polling question for everyone. I want to know: What is your level of training? And you can click on this, on your computer. Are you a medical student, a resident, an ophthalmologist, or are you an oculoplastic surgeon? So we’ll give you a couple seconds here to answer. And then we’ll pull that up, just so we can see who’s out there listening today. So it looks like most of you are ophthalmologists. There’s a few oculoplastic surgeons, and a couple of ophthalmology residents. So that’s great. So hopefully this talk will work for everybody. And we’ll keep going on. So the most common form of congenital ptosis that we see is what I call congenital myogenic ptosis, which is a dysgenesis of the levator muscle. Typically present at birth. And what you see when you operate on these kids is that their normal levator muscle is replaced by fibrous or fatty tissue. And this affects both the relaxation and the contraction of the levator muscle. So these kids have trouble not just with opening the eyes, but sometimes with closure, and you’ll notice lagophthalmos. So you’ll see this decreased levator function, eyelid lag, and lagophthalmos. And these kids, as you can see in the picture on the bottom there, typically have an absent or a poorly developed eyelid crease, and that’s because the eyelid crease is formed by the levator muscle’s insertion into the orbicularis. So this is one of my quick slides to think about. When you see somebody with ptosis, if it’s present at birth, it’s congenital ptosis. If it’s between the ages of 1 and 20 years of age, so if it comes in, and they say this just started in the last several months, and they’re in this age range, those patients need a complete workup. And that’s a complete neuro-ophthalmic workup, involving looking for things like myasthenia gravis, third nerve palsy, things like that. We won’t get into that in this talk. But I just want you to keep that in the back of your mind. If they’re between the ages of 20 and 50, and they have what looks like an aponeurotic dehiscence, that’s typically due to contact lens wear. And over 50 is typically levator dehiscence, which also might be due to contact lens wear, if they’re long time contact lens wearers, but typically it’s just age-related levator dehiscence. So let’s talk about the evaluation of a patient with congenital ptosis. And first we get a history. Is this something that happened because of birth trauma, for example? And what is the onset? Typically, kids with congenital ptosis, obviously, are born with it. Is there any degree of variability? Is there a family history of ptosis? Or any other craniofacial-type syndromes? And then an underlying medical history. Allergies and bleeding tendencies, when we’re talking about surgery. When we look at these kids, we first start, obviously, with the external examination, looking to see if it’s a unilateral or bilateral. And I will say: Congenital ptosis tends to be bilateral, although there are a lot of kids that have a unilateral, as you see in the top picture there. But it tends to be bilateral. And sometimes it’s just markedly asymmetric. And then looking for the presence or the absence of the lid crease, which just suggests the amount of levator function. Eyelid excursion or levator function. And we’ll talk about that in just a minute here. Orbicularis function, to look at closure. Looking for frontalis overaction is important, and you can see in this slide picture on the bottom there, that the little guy — you can see he’s cranking his brows. And this suggests that he has the desire to open the eyes, and it helps protect from amblyopia, and it also suggests that if you need to, doing a frontalis sling will be a reasonable procedure in this patient. And then looking for any abnormal head postures, specifically chin-up posture, as you can see in the kid on the bottom as well. He’s kind of tilting his chin up to help see under his ptotic lids. And then we specifically look at the eyelid, looking at the levator muscle. So we look for the levator function, which will be described in one of the slides coming up. The lid position in downgaze. And kids with congenital ptosis, again, that levator muscle doesn’t relax, because it’s been replaced by this fibrofatty tissue. And so you’ll see a lot of lagophthalmos in downgaze. And then checking the lid position with gentle closure, to see if they do have lagophthalmos with passive closure, the MRD1, or the margin reflex distance 1, which is a very helpful measurement from the corneal light reflex to the upper eyelid margin. And then looking for Bell’s phenomenon, to help protect the eye. Once we’ve lifted the lids in some of these kids, they will develop lagophthalmos, and Bell’s phenomenon is gonna help protect the cornea. So this is how we measure levator function. And really what we’re measuring is the excursion of the eyelid. We’re not truly measuring levator function, but this is our best test for the levator muscle. So we brace the brow, and we have the patient look from down to up, and that excursion of the eyelid in millimeters is what we record as the levator function. This is just showing an older individual, but she does have congenital ptosis. And you can see when she looks down and when she looks up, she has very little movement of that left upper eyelid especially, which is her more ptotic lid. And you can see she really doesn’t have any crease formation, when you look on the left picture there. And then we do a complete ophthalmic exam. Checking for vision. Because we want to make sure these kids aren’t amblyopic. Refractive error. There can be a plus cylinder at that vertical axis with some of these kids with significant ptosis. Pupillary change, looking for other causes of ptosis. Neurologic causes, as well as extraocular muscle, and strabismus. And then the remainder of the eye exam, including tonometry, slit lamp examination, and a dilated fundus exam. And this is the differential diagnosis. Just a short differential. And we’ll look at some of these disorders here in the next several slides. So Marcus Gun Jaw Wink is an interesting phenomenon, where there’s this synkinesis or miswiring between the third cranial nerve of the levator muscle and the trigeminal nerve. And what you see is, with stimulation of the ipsilateral pterygoid muscle, with opening the mouth or shifting the jaw, the eyelid goes up. This can be unilateral or bilateral. Sporadic or autosomal dominant inheritance. And it’s probably seen in up to 5% of congenital ptosis cases. And this is an older individual. Here you can see the ptotic left upper lid. And when she opens her mouth, you can see that eyelid comes to a normal position. And as you can imagine, this is a very difficult problem to treat. And what I tell the parents — and I’m gonna show you a little picture of a baby, while I talk here. You can see, as she sucks on the pacifier, that lid really retracts. The right upper lid really retracts. And what you need to tell the parents is there’s two things. There’s the winking portion, the abnormal miswiring, and then there’s the ptosis. And depending on the degree of each of those, you can make a decision on what you need to do surgically. So to treat the wink portion, you need to do a levator extirpation, where you resect a segment of levator muscle. And that can either be done in the orbit or at the aponeurosis. And there’s various ways to treat that. But once you do that, you’ve totally removed the drive to that lid. So you’re gonna have to put in a sling. So on levator extirpation — Crowell Beard described doing a bilateral levator extirpation and sling, even on unilateral cases, to get the best degree of symmetry. There is what’s called the Chicken Beard, where you extirpate the winking muscle and place slings bilaterally. I will say, for the most part, I usually do unilateral surgery on these kids, and that’s for most of the congenital ptosis things that we’ll talk about today. And then, if the parents want, then we can always put the sling in the other side at a later date. So blepharophimosis, or the congenital eyelid syndrome, is this triad of blepharoptosis of the lids, epicanthus inversus, the epicanthus coming from the lower lid, extending upward, and telecanthus, widening of the horizontal medial-canthal distance. And these kids also have a phimotic lid, which is the short horizontal aperture. Tends to be autosomal dominant, and really, there’s two types. Type I, that’s associated with primary ovarian failure, and then type II, which is not. And you can see the ptosis here, and then the widened medial canthi, the telecanthus here, and then the epicanthus inversus, and the phimotic lids as well. So the surgical treatment — usually this requires a sling procedure. I think it’s very difficult, at least in my hands, to fix this with a levator procedure. Although I know there are several surgeons that get good results with that. And then later down the road, telecanthus and epicanthus repair. And sometimes doing a canthoplasty. And basically the way I deal with these kids is like with any congenital ptosis. If the ptosis is amblyogenic, I fix that. If not, we wait until a later time. And usually I repair the telecanthus and the epicanthus as they get older, after age 12 or 13 or so. There’s various ways to do the epicanthal repair, and really, I’m not getting into that with this lecture. I want to talk more about the ptosis. But there’s the multiple Z-plasty epicanthoplasty of Mustarde. And then more typically what I use is this Y to V advancement, which works quite well, and is a little simpler. And I think actually heals better than that multiple Z-plasty. And just to show a quick slide on transnasal wiring, this is done — I typically do it with bilateral incisions. And I do the incisions as my epicanthoplasty incisions, and then what we do is we pass a drill bit across the septum, and we use actually — I use a lumbar puncture needle to help pass the wire across. And just showing a kid — this is three weeks out. So we did ptosis repairs with slings and bilateral epicanthoplasty and transnasal wiring. Congenital Horner syndrome’s fairly rare, and as you know, it’s a defect in the sympathetic innervation. Most commonly caused by birth trauma. However, you do need to rule out neuroblastoma in these kids, and they have a typical Horner syndrome triad of ptosis, miosis, anhidrosis, and they end up with iris heterochromia with a lighter iris on the involved side. Here’s a kiddo with congenital Horner’s, and you can see the lighter iris on the right side. A couple millimeters of ptosis. And a miotic pupil on that side as well. And there’s congenital fibrosis of the extraocular muscles, which is even more rare. Multiple inheritance patterns. And these kids are born with this non-progressive ophthalmoplegia, often with ptosis. And it’s very difficult. This woman here, you can see she’s cranking her brows up to try to raise her lids, and you can see she has a bilateral hypotropia and exotropia. And we operated on her with one of our pediatric ophthalmology colleagues, to try to realign her eyes and lift her lids a little bit, to get her some — at least an improved head posture. And I would say these are incredibly difficult cases. Here she is, 8 months out. So she still has a little ptosis on the left, I would say, but she’s much, much improved head posture. Then there’s mechanical ptosis. This is capillary hemangioma. Causing a mechanical ptosis of the upper lid. This is a little girl with neurofibromatosis, with a neurofibroma in the left upper lid, causing a mechanical ptosis. And finally, this little girl with a large abscess of the right upper lid, causing a mechanical ptosis. So the surgical indications — and I’ve got to say, I’m not a pediatric ophthalmologist. I’m an oculoplastic surgeon. A lot of these are referred by our pediatric ophthalmology colleagues, and it’s for these reasons. So to treat the amblyopia that’s developing, or like we talked about earlier, astigmatism from the lid position. If they’re developing a head tilt or a chin-up position, as you see in this little guy. And then for psychosocial reasons. And what I tell parents is, if the ptosis is not causing amblyopia or any other ophthalmic problems, we usually wait ’til about age 5 or 6, until the kid’s about to enter school, and then we’ll proceed with ptosis repair at that point. Again, we’ll perform — I’ll perform ptosis repair on a one week or two week old baby if the lid is completely down, and we feel that it’s amblyogenic. But typically we do wait ’til one to two years, if we can. And then, like I talked about, for psychosocial reasons, usually age 5 or 6. So these are the major surgical options that we have. Levator resection, Muller’s muscle conjunctival resection, and then what we call full thickness resection or levator plus, involving a resection of Muller’s muscle, tarsus, and conjunctiva. And, of course, the frontalis sling. And we’ll talk about all of these. So there are several classifications of ptosis, and how much surgery to do on these children. And this is the one — Crowell Beard’s kind of the grandfather of congenital ptosis repair. This is the Beard classification. And you can see he determines the amount of levator resected based on the degree of ptosis and the levator function. I’m a much more straightforward thinker, and I basically, if the patient has good function, I’ll do a levator procedure, a Muller’s muscle procedure. If they’re in that in-between phase, maybe 5 to 10 millimeters, or 5 to 7, as it says here, a full thickness or levator-plus tarsectomy-type procedure, and then if they have poor function, I usually go with a frontalis sling. So if they do have good levator function, 8 millimeters or more, we do a phenylephrine test. And if they have a good response, I’ll do a Muller’s muscle conjunctival resection. If they have a poor response, then we’ll go with a levator procedure. So the phenylephrine test — we use 2.5 phenylephrine, and then we look at the MRD1 after 10 minutes. This is obviously in an adult patient here. You can see with the ptosis in the right eye, and with the red-top drop, you can see after 10 minutes her lid comes up to a nice height. And the nice thing about phenylephrine is it is diagnostic, and it helps you decide on your therapy, but it also might unmask a contralateral ptosis, or a Hering’s dependency in the other eye. So if the ptotic lid comes up and the other lid comes down, it will help you determine if you need to do surgery on that contralateral eye. So if the patient responds to the neosynephrine test, then we will typically proceed with the Muller’s muscle conjunctival resection. And this was first described by Dr. Alan Putterman in 1975. It has a very high success rate. I like the Muller’s muscle procedure. It’s a fast procedure. It’s much more predictable — at least in my hands. And the only really relative contraindications that I can see are glaucoma, conjunctival scarring, or any other conjunctival disease. And just to show a couple patients, this was a congenital ptosis patient with a ptosis of the right upper lid, and here she is, six months out, after a Muller’s muscle conjunctival resection. Very happy with her result. Here’s a short video that we put together, showing our technique of Muller’s muscle conjunctival resection. I’ll get this to play here. And like I said, I love this operation, because it’s really quick and easy, and very predictable, and the contour typically is excellent. So I use a 4-0 silk through the eyelid margin, evert the lid, and then I take a toothed forceps and just gently peel the conjunctiva and Muller’s muscle from the underlying levator. And I make marks at half the distance. My typical resection, if the neosynephrine brings the lid to a good point, we’ll do an 8.5-millimeter resection, and so we’ll mark 4.25 millimeters from the superior tarsal border with the marking pen. And then I like to run — this is a 6-0 silk suture — run at half the resection distance, so 4.25 millimeters. And then I’ll take those sutures and have the assistant elevate it and put traction on my lid margin suture, and then this is the Putterman clamp to clamp the tissue at the superior tarsus. And then pull out the 6-0 silk suture. And then I use a double-armed 6-0 plain gut suture to close this incision. And what I do — I run this stitch — you can see as I move my hand out of the way — approximately 1 millimeter below the clamp, from lateral to medial, and then I’ll run it back, medial to lateral. And while I’m showing this, I just want to say I typically — like I said, I usually do an 8.5 to 9-millimeter resection, if the neosynephrine brings the lid to a good position. If the lid is a little low, and JD Perry, Julian Perry, from Cleveland Clinic, was the one who described this technique — if the lid is a little low, then you can add a millimeter for millimeter resection of tarsus. So if I put in the neosynephrine, and the lid is about a millimeter lower than I would like it to be, I’ll put my Putterman clamp over 1 millimeter of tarsus. So include a little tarsus in our resection. And you can see here I’ve turned and I’m coming back the other direction. So it’s really a double horizontal mattress, and I really like this technique. Because there’s no closure, once you’ve cut off the tissue. Which becomes difficult, as there’s bleeding typically from the Muller’s muscle. But you basically close your incision before you make it. And this works incredibly well. I can’t say how much I love this operation. So I run the stitch from lateral to medial. The medial to lateral. The suture bites are about 5 to 6 millimeters apart. And about 1 millimeter inferior to the Putterman clamp. Then we take a 15 blade, metal on metal, aim to the sky, and cut off the tissue. And then I pull both ends of my double-armed suture, and this can obviously be done with a single-armed suture, and just pass it from external to internal, then run it and bring it back external. But here I’m using a double-armed 6-0 plain gut suture, and I tie it externally in the lid crease, and then I just trim it there. And that’s my Muller’s muscle conjunctival resection. So levator resection is a little bit more difficult in kids. In adults, we typically do this under local or sedation with local. But once you add general anesthesia, it really adds a whole nother layer of complexity, because the amount of resection becomes the question. So there’s a couple ways to do it. You can either do a predetermined amount of levator resection, as per the Crowell Beard, or you can do it based on how high you want to leave the lid at the end of the surgery. And this is a table from Berke’s, so if they have good function, you can leave the lid 4 millimeters below the limbus. If they have moderate function, you can see as you go down. And then if they have poor function, you want to leave it basically at the limbus or above, I would say. And then if they have less than 4 millimeters, we usually do a frontalis suspension. I like this technique that Dr. Sonny McCord describes. He calls the gaping formula, and that’s how much lagophthalmos you leave on the table. So it’s the amount between the upper and lower eyelids. So in his formula, it’s the amount of ptosis — this is for congenital ptosis — plus 3 millimeters is how much lag you should leave. So, for example, if the patient has 3 millimeters of ptosis, the distance between the upper and lower eyelids at the end of the case should be 6 millimeters. I don’t have a video on levator resection. I think that’s been covered in some of these other Cybersight talks. But I have a quick just… Surgical series here. So an incision in the lid crease. Then we open the orbicularis, orbital septum, and there’s the preaponeurotic fat pad, and then we find the levator muscle, which, as we talked about earlier, is this fatty infiltrated muscle that you see in congenital ptosis patients. And then we pass a suture horizontally through the tarsus, and then back underneath the levator muscle, and advance it onto the tarsal plate. I always avert the eyelid when I do levator resections, just to make sure the suture doesn’t pass full thickness. I use a 5-0 Mersilene suture, which is braided, so that if it is full thickness pass, it can become irritating to the cornea, and you can get a keratopathy. So I always check and make sure that my pass is not full thickness. And then we pass it through the muscle and advance it onto the tarsal plate. Here’s a little guy before and after levator resection. And you can see you can get really nice results with this operation. So I wanted to do this polling question, to see what the audience liked. So what’s your preferred surgical technique for what I call fair levator function ptosis? They have 5 to 10 millimeters of levator function. And there’s multiple answers. But I just wanted to see what people like. So maximal levator resection, doing almost a Whitnall’s, or a Whitnall suspension, levator resection plus tarsectomy and Mullerectomy, or a frontalis sling. So these are in folks with 5 to 10 millimeters of function. So we’ll give you a couple seconds here to vote, and then we’ll see what you all thought. And then I’ll show you what I like to do. All right. Survey says… So 54% prefer a maximal levator resection. I’m sorry. 38% do a levator resection plus. And 8% will do a frontalis sling. All right, good. That’s great. So we have across the board. But split between the maximal levator resectors and the levator resectors tarsectomy folks. So I like this procedure. Which basically adds a tarsoconjunctival Mullerectomy to a levator advancement-type procedure. And I’m gonna show you some videos and some results. So this is where I got the idea. This was not my idea. John Lindbergh, his fellow wrote this up probably over 10 years ago now. And basically they said: For mild amounts of ptosis, do a 2-millimeter tarsectomy and a 4-millimeter Mullerectomy. For moderate, 3 millimeters of tarsus, and the idea is twice as many millimeters of Muller’s as tarsus. And then for severe, 4 to 5 of tarsus and 8 to 10 of Muller’s. So this is what it looks like. And this is from their publication, which was actually in 2008. So nine years ago. And there’s the reference there at the bottom. And basically it’s resecting this ellipse of tissue involving the tarsus inferiorly and Muller’s muscle and conjunctiva superiorly. And you can see through the eyelid there, once they’ve resected it, and then advanced everything back together on the bottom right. So I’ll show this quick video. Of our technique. And even though they’re under general, I always use local anesthetic with epinephrine. And I put a shield in, since I’m doing a full thickness resection. I use a 15 blade to make my decision, and then I like the hot-wire, high temp cautery, to dissect down to the tarsus. So this is this the suborbicularis, planar to the tarsus. Then I’m gonna open the septum up above, and you can see the fat, preaponeurotic fat, which usually is this kind of billowy fat in kids, and then the levator aponeurosis below. And then I’m gonna dissect the levator from the underlying Muller’s muscle, and there you can see the anatomy marked out. The peripheral arcade is kind of your anatomical guideline. And we talked about this. So it’s twice as many millimeters of Muller’s and conj as tarsus. This is a 3 and 6-millimeter tarsectomy, 6-millimeter Muller’s. And then I use 6-0 chromic or 6-0 vicryl to reattach the conjunctiva and Muller’s muscle. And I try to leave the suture in the Muller’s muscle, so it doesn’t rub against the cornea again. So multiple chromics. And you can see, once you’ve done that, the lid really comes to a nice height. Then I’m gonna advance the levator with 5-0 Mersilene. And I’m gonna tell you another little trick. And I learned this from Bryan Sires. Is to put your levator suture at the nasal pupil and the temporal limbus. And I think since I started doing this, I found my contours much, much improved. So that’s where I put my two levator sutures. If I do a single levator stitch, I’ll put it in between that area. Then here, I’m reforming the crease, sewing the inferior edge of orbicularis to the levator, and now I’m just closing the skin with interrupted 6-0 plain gut sutures. So the crease formation’s with 6-0 vicryl… And there it is, at the end of the case. And I’ll tell you, since I started doing this procedure, I’ve been able to get those kids that, for several years, I just couldn’t get my ptosis kids with fair function, where I wanted them. But now I’ve found I’m able to really get those lids into a much improved position. Here’s a little guy with asymmetric bilateral ptosis. A little girl. This girl had had three or four prior procedures on that right eyelid, and I did a tarsectomy, Mullerectomy, and a levator advancement. She’s still probably a little bit low, but I think she’s at least clearing her visual axis. It looks much more symmetric. Here’s a little guy with fairly severe ptosis. We did bilateral levator and tarso-Muller conj resection. Here’s a little girl, five weeks postop. And again, these are the kids. They do have a crease, so I know they have some levator function. And advancing the levator and doing the addition of the tarsectomy-Mullerectomy really helps lift that lid. So for poor function, and we’re talking, again, less than 4 millimeters of levator function, I prefer a frontalis sling as well. I will say the caveat is: The kid who has poor function and no frontalis action. And those kids — I tried frontalis slings, but if they don’t have the drive to lift the lid, doing a sling’s not gonna help. So in those kids, I’ll do some tarso-Mullerectomy, maximal levator-type procedure, to try to get the lid as high as I can. And those are difficult cases too. So here’s the variety of suspension materials. I have another — this is, I think, my last polling question. But I’m really interested to see what people like. There’s silicone, there’s autologous or banked fascia, there’s sutures. Some people are using the palmaris longus. And let’s see. What do you guys use? So I think the most used, at least as far as I can tell, are silicone, or either autologous fascia or banked fascia. So this is in a five-year-old patient. So it is possible to harvest the fascia lata. But what’s your preferred material? So I’ll give you a little bit of time to answer this question. And let’s see. So most people are silicone users. So 71% said silicone. 13% said autologous fascia. 4% said banked fascia. And 13% said other. Okay. So let’s talk about what I do. I like silicone. And I’ll tell you why. I also use autologous fascia lata, which I think is the gold standard. And if the parents want the patient’s own tissue, I’ll use fascia, and I think you get great results with it. But I’ll tell you why I like silicone. It’s adjustable, it’s reversible, and it’s elastic. I think you get less lagophthalmos. And it’s much easier to work with. And of course, it doesn’t have a donor site morbidity that the autologous fascia does. So there’s many, many ways to do a frontalis sling. Whenever there’s a lot of ways to do things, that means there’s no right way. But the traditional sling is done with several incisions, either two in the lid and then three in the forehead, or a lid crease incision, and then three in the brow-forehead region. And this gives you a nice contour. And the sling material goes in as a pentagon. I have really adopted this — what I call minimal incision. Which is a small incision in the eyelid crease, a small brow incision, and more of a triangular approach. And I’ll show you — I think you get excellent results, without having to put that forehead incision in. And I know some people are putting their central brow incision lower. But I’m gonna tell you, this really works nicely. It’s really a simple way to do it. So I’m gonna show you my technique for frontalis suspension. So I have a central lid crease incision. And a central brow incision. And again, I think the area to suture the sling material — and I’m kind of getting ahead of myself — is the nasal pupil and temporal limbus. We dissect down. Again, I like the hot-wire cautery to dissect down in the suborbicularis plane. I take the needles off that they package with this frontalis sling material. And I’ll show you why. I like a curved abdominal taper needle. This is 5-0 Mersilene suture to secure the sling material to the tarsus. And I usually do it in two places. Occasionally, to help with contour, we need to adjust it. Make sure that we’re not full thickness. And then I like this curved abdominal taper needle. And I’ll show you — you can see why here. The curvature works perfectly for the eyelid. It’s kind of like a smaller version of the right fascia needle. But it really works well to pass the silicone through the eyelid. And you can see I have a Yeager lid plate there, protecting the globe. And then I’ll pull on my sling material, which is silicone, and make sure I have a good contour. And then I close the orbicularis muscle to the deep tissue, the levator and the pretarsal tissues here, to help form the lid crease. And that’s with a 6-0 vicryl suture. And I’ll put several of those to help create a crease. And you can see that when you pull on the sling material, you can see the crease form. And then I use 6-0 plain gut. And I do interrupted sutures in kids. I’ve just had several kids that have pulled out running sutures. So I finally learned. And I’ve done just interrupteds. Then the sling — I use the Visitec Rod Sling. And it comes with this Watzke sleeve, the retinal Watzke sleeve that they use for scleral buckles. And I put that over the sling and then tighten it to bring the lid… And usually it’s just at the limbus, is where I leave it. And then I tie a 5-0 vicryl around all of that. Because I have had those slip out if I don’t secure it. And it helps you find the sling later. And then cut off the excess sling material. And I’ve already created that subcutaneous pocket in the brow to tuck it into. And then we’re gonna just tie the… I’m sorry. Close the deep tissues with the 6-0 vicryl, and then again, I use 6-0 plain gut on the skin edges. And there we are at the end. So here’s that little baby I showed earlier, with the Marcus Gunn Jaw Wink. And so when she wasn’t winking, she had almost a complete ptosis of the right upper lid. And interestingly, this little girl had a congenital cataract in the other eye. So this was her good eye. That was ptotic when she wasn’t winking. Here’s a little girl with bilateral congenital ptosis. And this is after about a month. And you can see… These incisions heal really nicely in the eyelid and the brow. Here’s an older woman. This woman had had multiple procedures in her eyelid to try to get that lid into a normal position. And I did this sling. And again, this is that triangular contour. Gives a really nice contour. So occasionally, they have persistent ptosis, needing surgery. And with the sling, it’s easy. You can just tighten it up. Occasionally you do need to replace it. Lagophthalmos, and I have all these kids using artificial tear ointment regularly. And then — especially at bedtime. Sometimes you do get contour abnormalities or exposure. And you can adjust the sling as needed for them. So in conclusion, I think you need to do a thorough clinical evaluation in all these kids. And then the surgical treatment is really dependent on the type of ptosis, the health of the eye, and the levator function. That’s really the most important number. And then if they do have occlusive amblyopia, I put a sling in right away. And I use — even that silicone sling you can use in infants. And it heals really kneels. And I know people have been worried about the sling being visible under the skin, but the way we pass it deep, with that needle, I have not had that be a problem. All right. So now I’m gonna open it up for questions, and see if anybody has any questions — you can just type those in. I don’t see any right now. So I got a couple questions here from the Cybersight guys. So any drug treatment? I don’t know of any drug treatment for congenital ptosis. Can crutch glass be the treatment option for frontalis sling surgery to reduce risk of sling exposure and secondary infection? I don’t use ptosis crutches very often. I’ll tell you… Especially on kids. I typically will use them on an adult, and the one place I’ve found them to be helpful is actually with blepharospasm-type patients. Or myotonic dystrophy or myogenic dystrophy-type patients. I like, as I just discussed, silicone is really my preferred material for frontalis suspension. And that’s… Double elevator palsy and jaw winking — and those are difficult. And we talked about that earlier. But jaw winking? It depends. Again, how much is the wink and how much is the ptosis? And on those patients, I will operate on the ptosis as early as needed. So if they have amblyogenic ptosis, like they had in that little kid I just showed at the end of the talk, I’ll do that at… I think that kid was three or four weeks old. If not, then we’ll talk to the parents and decide: Do we want to take out the levator for the wink? Or just deal with the ptosis? Or both? And it’s really a discussion with the family. All right. I have some questions coming up live. How do you manage a child with poor Bell’s phenomenon and severe ptosis with amblyopia? That’s a really hard question. And what I would do in that case is do a sling, and leave it a little bit lower than I normally would. Because I know the sling I can always adjust. But you want it to clear the visual axis, and basically the parents are gonna have to lubricate… And again, I like silicone, because it has the elasticity, and I think they get better closure. Duplicated elevator resection is preferred? So let’s see. I really don’t understand that question. But I prefer levator resection, I guess, in kids that I’m doing levator surgery, rather than kind of pinching the levator together. Could you again share the needle details that you use for sling surgery? Yes. So I like the… There’s several versions of it. And you’ll have it in your hospital. The general surgeons use it for closing abdominal fistulas, is what it is. So they’ll call it a fistula needle. It’s a half circle. And you can either use the cutting or the tapered. Either one works just fine. So it’s a half circle needle, and it’s about… Depending on the size of the kid, you can use either one that’s about a centimeter or 2 centimeters. And sometimes they’ll give me these huge ones, these 3 centimeter ones, that’ll work as well. But it’s much bigger than the eye and the nurses don’t like it. Like to see that. So that’s the needle that I use. So it’s a half circle, abdominal closure needle. How do you feel resection of tarsus might come back to bite you? Are there any drawbacks? That’s a great question Ian just asked. So the way I think a full thickness resection tarsus can come back to bite you — and in my training, I was told you never, never, never resect tarsus. But I’ve found… I get excellent results with it. So the way it could come back to bite me, I guess, is if you needed the tarsus later down the road. Say, for Mohs reconstruction, if the patient has skin cancer. Number two, if you destabilized the lid, if you took too much tarsus, and the lid kind of folded on itself, that might be a problem. I have not seen that with this procedure. And then I have not seen any drawbacks. I will tell you, I have seen some of those kids where I have had to go back and advance the levator more and tighten the levator muscle, and that has not been a problem. I guess I haven’t really had problems with it, but those are the ones that I would consider. What are your common complications using silicone for frontalis sling? So granulomas do occur. As Andrea said in her question here. So granulomas and extrusion. So I would say granulomas occur probably less than 5%, where patients have a reaction to the sling material. Those are fortunately rare. And I will tell you, there was a recent paper. I have not tried it in this, but just to put this out there, there was a recent paper using timolol drops for pyogenic granulomas. I have used it on a congenital granuloma, and had it melt away. So just to put that out there. But typically, I’ll treat them with topical steroid antibiotic drop. If it’s external, I’ll use an ointment. And see if it melts away. And if not, then I’ll just excise it. And then extrusion does occur, and here’s why. I think if you placed the sling too superficially, it will lead to extrusion, or it can lead to extrusion. So it’s really important to make sure you make that pocket in the brow tissues, that subcutaneous pocket, and get everything tucked under there, number one. Number two, when you’re passing the sling, and you can see that in the video, it’s passed deep. So I want to be deep to the septum, and I want to come out deep in my brow incision. If it comes out superficial, and it catches the edge of the incision, occasionally that’s what leads to the extrusion of it. I haven’t seen extrusion other than the ends in the brow kind of pointing out through the incision. I think because it was too superficial. I have not had it come through the lid. At least, a silicone sling. So those are the questions that are up there. If you have any other questions, I’m happy to answer them. There were a few more on the Cybersight screen. I can go through some of these. And if anybody has any other ones, please throw them up there. Is there an upper age limit for the use of autologous fascia lata for frontalis slings? I think there’s a lower age limit. About 5. The leg muscle needs to be well enough to develop. But I don’t know that there’s an upper age limit. Please discuss unilateral slings pros and cons. Great question. So let’s talk about that. I typically do a unilateral sling. And I’ll tell you why. If a patient has a unilateral ptosis, I do a sling on that eyelid. If they have an asymmetry afterwards, then we can go back and do the sling in the other eye. I know some people recommend bilateral slings on all patients, to improve symmetry. I’ll tell you, I’m a parent of three kids, and I have a hard time telling a parent to operate on the normal eyelid. I’ve talked to parents about it, and I really haven’t done it. So I can’t tell you are, I have very little experience with bilateral slings for unilateral ptosis. Then for management of blepharophimosis, another difficult problem, and I think we talked about this earlier, that… I typically perform the ptosis repair early, and then later deal with the medial-canthal issues, the epicanthus and the telecanthus. And at that time, we can adjust the ptosis, if needed, as well. So that’s my… I usually do the ptosis first, age 12, 13 or so, and then we’ll start to talk about doing the medial-canthal surgery. There’s another question for Andrea. Am I concerned about affecting meibomian gland function when I do a tarsectomy? I have not had a problem with that, but that’s an excellent question. I don’t know… I don’t test meibomian gland function, so I don’t know if that becomes an issue down the road. I have not seen any problems with this procedure, and I’ve been doing it for the last ten years or so, and I have not seen dry eye issues related to meibomian gland specifically.