This video demonstrates Muller’s Muscle-Conjunctival Resection (MMCR) surgery in a patient with bilateral upper eyelid ptosis and a good response to preoperative phenylephrine testing. The surgical steps of internal ptosis repair, indications and contraindications of the surgery are described here in detail.
Surgery Location: on-board the Orbis Flying Eye Hospital, Kingston, Jamaica
Surgeon: Dr. Bradford Lee, Bascom Palmer Eye Institute, USA
DR LEE: She actually came in complaining of ptosis of the right upper lid. And her MRD1 measurement was about -0.5 on the right, and about 2 to 3 on the left. However, once we manually lifted her right upper lid up, her left upper lid dropped down to about an MRD1 of about +1. So we explained to her that if we only do a ptosis repair on the right side, because of the Hering’s response, the left side would drop down and relax. So we talked to her, and she said: Well, I’d rather my left eye be a little bit more open as well. So just to show you the landmarks, this is the superior border of the tarsus here. I’ll give a little bit of local anesthetic now. And in this side, we’re planning to excise 10 millimeters of conjunctiva, plus 2 millimeters of tarsus. So the way I set the clamp is actually to 4 millimeters. And then we’re gonna advance it onto the tarsus. So it’s actually gonna end up being 10 millimeters of conjunctival Mullerectomy excision, plus 2 millimeters of tarsus. So here I’ve set it to 4 millimeters now. We’re gonna first mark out how much resection to do. So here’s the maximal height of the tarsus. I’m aligning it with the superior border. And I’ll make a little mark here. Do a 4 millimeter mark here. Roughly about there. And one over here. So this is a traction suture. I’m just gonna make a little short pass through the conjunctiva here. Short pass through the conjunctiva. That’s the second one. So this is a 6-0 fast gut suture that will typically dissolve over the course of about 2 weeks. I like to use this because you don’t have to take out any stitches. If you didn’t have 6-0 fast gut, you could use a nylon or a prolene suture, and basically remove it after a week or so. 7 to 10 days would be fine. So I’m gonna show you how this works here. It’s a very simple clamp. It engages the conjunctiva and Muller’s muscle, and you slide this down, and it locks it. So you should be able to do this with one hand, ideally. You clamp it, and then you engage it. So now I’m applying the clamp, and in her case, we’re gonna advance it about 2 millimeters onto the tarsus. Like that. And I’ve just engaged it now. So we can actually recycle our needle. So we’re gonna just pull this through. Now I’m just gonna anchor the suture to the skin. So I take a short pass through the skin. Through the eyelid crease area. And we’re just anchoring the stitch now. So I’m just tying it off on itself. And I’m gonna place the needle close to where my anchor is. We’ve rotated it, and now I’m gonna finish my pass. So I’m ideally coming out just about 2 millimeters below my clamp here. Here’s my needle here. So this is a full thickness pass through the eyelid. If you’re combining it with a blepharoplasty, you can perform the blepharoplasty, and instead of anchoring it to the skin, you anchor it to the orbicularis. Now where we begin our running horizontal mattress stitch underneath the clamp, and the goal here is to actually pass very close to the clamp without passing into the clamp, or you’ll just dull the needle, and you can’t pass metal through metal. So I’m gonna just follow the arc of the needle. Here you can see I’ve passed the needle right underneath the clamp. And then I space it a few millimeters apart here. Maybe like about 3 to 4 millimeters. Then I pass it under again. Hugging the metal, but not passing into the clamp. Again, underneath the metal clamp. And then you see it coming out right under the metal here. Some of my colleagues and friends have switched to doing a single interrupted stitch. Whereas the traditional way is that we run it across the entire clamp. And some people actually run it across and then they backsew it another time. But basically we’ve found that you can just do a single interrupted stitch, and that’s actually sufficient for this procedure to work. I generally run it about three times, back and forth, and feel that that’s sufficient. So now I’ve come to the end of the clamp here. Again, we’re gonna do place, rotate, and complete the pass. And then I’m gonna make a long pass, and try to come out through the eyelid crease here. So one Q-Tip is gonna be used, just to protect the lower lid down below, and one Q-Tip is gonna be to evert the lid margin, so that I can come under the clamp. I’ll take the 15 blade now. And I’m just gonna come metal on metal with a slight bevel. Beveling upwards. In a sawing motion. So we’re checking here. It’s intact. So I did not cut the suture. But if you did cut it, and it doesn’t unwind itself, sometimes you can just leave it, and it will stay intact. But if you cut it somewhere where it really splays apart, first of all, you’ll notice a little bit of oozing from the conjunctival edge, and you can still directly sew the conj to the superior border of the tarsus. So you can either run it across or you could put a few buried interrupted stitches across to help bring the edges together again. Once we’ve come to the end here, we just anchor and tie this off. So again, very close to where it’s coming through the skin. I just make a very short pass. And I tie the suture off on itself. I actually prefer internal ptosis repair, if possible. And generally the way I decide is we do what’s called the phenylephrine test and we see how they respond. The phenylephrine test, if they respond to the drop, and the lid goes up with phenylephrine, it generally means that they would be a good candidate for this procedure. And she responded quite nicely to phenylephrine. We’re doing the ptosis repair on the left side, even though if you look at her preoperatively, you might say: Oh, the left side looks fine. But you have to check for that. So on this side, it was not as droopy. So we’re only doing an 8 millimeter conjunctival Muller’s muscle resection. I generally say that 8 millimeters of surgery simulates the effect of the 2.5% phenylephrine test. So when she had the 2.5 phenylephrine test in both eyes, her left side raised up to an MRD1 of about 3.5. Which is a nice amount. Her eyes are open. They’re not over-open or retracted. But they’re also not droopy. So we said that a goal of about 3.5 is what we’re aiming for. So since she raised up to 3.5 with the phenylephrine drop, well, the phenylephrine drop simulates 8 millimeters of surgery on average. And so that’s why we’re doing 8 millimeters in surgery. Kind of a contraindication to this procedure. So any patient who’s had a trabeculectomy where you’re worried about potentially injuring or perforating or causing trauma to the bleb, generally any patient who’s had conjunctival surgery — they may also have some scarring. So patients who have had, you know, whether retina surgery, glaucoma drainage implant, the conjunctiva has been played with, and sometimes there’s already some scarring. So I generally prefer not to do the surgery. Or if they have very severe glaucoma and we’re thinking that they may need a trab down the road, again, I generally try to stay away from it, because you don’t want to further shorten the fornix. Or overshorten it, based on preexisting scarring. Naturally, if they had ocular cicatricial pemphigoid, or any type of cicatrizing conjunctivitis, that’s a no-no for doing this surgery. Because you don’t want to further foreshorten their fornix. There’s a few other ones. Like, say, if the patient has severe ptosis, and this procedure may not be enough. So if they start off with an MRD1 of -3, -4, and have really poor levator function and myogenic ptosis, this is probably not gonna be enough to address it. So then we switch to either external levator advancement or possibly even a frontalis sling, if they have really poor levator function. And if you look at the statistics when they’ve done surveys of the American Society of Ophthalmic Plastic and Reconstructive Surgeons, the ASOPRS members, there’s been a definite shift over time from people doing predominantly just external levator advancement to conjunctival Mullerectomy surgery. And it’s a newer technique, and there’s a definite shift. And you can see why. It’s predictable. It’s fast. There’s no patient cooperation necessary. Oh, post-op care. Typically ophthalmic antibiotics, steroid ointment, twice a day in the eye, for about one to two weeks, and that’s sufficient. What I tell patients is that sometimes — even right after the surgery, you can see the lid higher. But sometimes it takes several weeks for the lid to arrive at its final height. So it’s certainly not uncommon to see a patient at week one and see that the lid hasn’t gone up much. And is still swollen. And then it will gradually, over the course of the next month sometimes, it will continue to go up. I like to sometimes irrigate the fornix just a little bit, because sometimes you can have a little coagulated clot form up in the superior fornix. And if it comes out on patients, they just freak out, even though it’s nothing harmful. And that’s the end of the procedure.
May 13, 2019