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Surgical Management of Complete Blepharoptosis With No Levator Function From a Compressive Third Nerve Palsy
Steven A. Nissman, MD ABSTrACT

A 94-year-old monocular woman with a posterior communicating artery aneurysm developed a compressive third nerve palsy with complete blepharoptosis and abduction of her seeing eye. It was believed that she was not a good neurosurgical candidate for aneurysm repair. Her ptosis was managed successfully with an in-office Whitnall sling procedure combined with a superior tarsectomy. The author describes this safe and effective method for surgical management of complete ptosis with zero levator function. [Ophthalmic Surg Lasers Imaging 2008;39:508-510.]
INTrODUCTION

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Figure 1. (A) Preoperative photograph showing complete right ptosis. (B) Abducted right eye from oculomotor nerve palsy.

CASE rEPOrT

Surgical correction of blepharoptosis from a third nerve palsy is atypical because the underlying pathology is usually corrected, resulting in improvement of lid function. Moreover, the ptosis is often intentionally not corrected because this would expose a strabismic eye and cause diplopia. I present the unique scenario and describe a monocular patient with complete ptosis and zero levator function who required surgical intervention to clear her visual axis and allow her to see.

From Nissman Eye Associates, Plymouth Meeting, Pennsylvania, and Scheie Eye Institute, University of Pennsylvania, Philadelphia, Pennsylvania. Accepted for publication July 31, 2008. Address correspondence to Steven A. Nissman, MD, 699 West Germantown Pike, Plymouth Meeting, PA 19462.

A relatively healthy 94-year-old woman with a partial pupil involving complete somatic third nerve palsy in the right eye from a posterior communicating artery aneurysm of 4 months duration was evaluated (Fig. 1). After neurosurgical consultation, she was determined to be an unsuitable candidate for surgical intervention of the aneurysm due to her advanced age. Visual acuity in the right eye was corrected to 20/50 with a mild cataract and visual acuity in the left eye was counting fingers due to a previous central retinal vein occlusion. She had zero levator function and zero Bells reflex in the right eye due to her palsy. No systemic anesthetic medication was used. The skin of the upper eyelid was anesthetized and a supratrochlear nerve block was performed using 2% lidocaine with 1:200,000 epinephrine. A lid crease incision was made 10 mm superior to the eyelid margin. Dissection was performed through the orbital septum and preaponeurotic fat to expose the levator muscle and aponeurosis (Fig. 2). The patient had a Fasanella-Servat procedure performed previously, so her tarsus was found to be shortened by approximately 3 mm; this essentially served as a superior tarsectomy.

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Figure 2. View of levator palpebrae muscle transitioning into aponeurosis (Whitnalls ligament is seen as the white band superior to the levator, just deep to the orbital fat).

Figure 3. Suture tied from superior tarsus to Whitnalls ligament (seen as the white structure pulled up to the superior aspect of the incision).

Figure 4. Degree of palpebral fissure opening on the table at completion of the surgery (incidental subconjunctival hemorrhage from corneal protector insertion).

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Figure 5. (A) Two weeks postoperatively. (B) The patient is able to close the eye with less than 1 mm of lagophthalmos.

A Whitnall sling was performed by suturing the superior tarsus directly to Whitnalls ligament (maximal levator resection) using two 5-0 polypropylene sutures in the standard horizontal mattress fashion (Fig. 3). The amount of palpebral fissure opening at the end of the case was estimated using the gaping technique described for congenital ptosis by McCord and Tannenbaum,1 which calls for the lid opening on the table to be the amount of ptosis in millimeters plus three additional millimeters. I estimated the ptosis below the visual axis to be 5 mm, so the lid was left open 8 mm on the table (Fig. 4). The skin was closed with running 6-0 silk suture. Postoperatively, the patient achieved an excellent functional outcome, with the visual axis cleared and less than 1 mm of lagophthalmos (Fig. 5). There was only minimal corneal punctuate staining that was managed with artificial tears and lubricating ointment at night in addition to taping the eye closed at night to prevent exposure. The left lens of her glasses was subsequently frosted to eliminate any sense of diplopia.

DISCUSSION

Treatment recommendations have always presented a dilemma in patients with severe unilateral ptosis with poor levator function. Surgical correction of complete ptosis from a third nerve palsy is highly unusual and this case was unique due to the monocular status of the patient requiring clearing of the visual axis. With no Bells reflex, postoperative corneal exposure was a significant concern. It was important to limit the patient to an in-office procedure because the emotional stress of an operating room setting may have caused an elevation in blood pressure and predisposed her to a rupture of the aneurysm. For this reason, as well as concern of postoperative lagophthalmos, a Whitnall sling procedure (with superior tarsectomy) was thought to be a better option than a more painful frontalis suspension. The Whitnall sling procedure offers the advantages of preserving all muscular elevating structures of the eyelid, offering

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better cosmesis, and providing some dynamic lid function. In this patient, the postoperative outcome was ideal and there were no significant problems with ocular exposure due to preserved ability to close the eye. The Whitnall sling was originally described in 1990 by Anderson et al.2 In 1993, Holds et al.3 presented their technique of a Whitnall sling combined with superior tarsectomy for correction of severe unilateral ptosis; however, in their case series, which consisted primarily of congenital ptosis, all patients had some degree of levator function (an average of 3.7 mm). Their surgical technique was somewhat more complex than the one presented here and they did not address the situation of a patient with zero levator function.

This case represents the first report in the literature of correction of a complete ptosis with no levator function from an inoperable third nerve palsy.
rEFErENCES

1. McCord CD, Tannenbaum M. Oculoplastic Surgery. New York: Raven Press; 1987. 2. Anderson RL, Jordan DR, Dutton JJ. Whitnalls sling for poor function ptosis. Arch Ophthalmol. 1990;108:16281632. 3. Holds JB, McLeish WM, Anderson RL. Whitnalls sling with superior tarsectomy for the correction of severe unilateral blepharoptosis. Arch Ophthalmol. 1993; 111:1285-1291.

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