2013

Orbit, 2013; 32(3): 190–193! Informa Healthcare USA, Inc.

ISSN: 0167-6830 print / 1744-5108 online

DOI: 10.3109/01676830.2013.771679

CASE REPORT

Levator-Muller’s Muscle Recession with Tarsorrhaphy:A Technique for Corneal Protection in Cases with

Cicatricial Upper Eyelid Retraction

Avinash Manna, Purnima Mehta, and Harpreet Ahluwalia

University Hospital Coventry, Coventry, United Kingdom

ABSTRACT

Aims: Cicatricial upper eyelid retraction with exposure keratopathy and impending corneal perforation requiresprompt intervention. Standard procedures such as isolated levator recession, botulinum toxin, and lid weightswill only induce a partial ptosis. Conventional tarsorrhaphy, though ideal to achieve complete closure, is likelyto result in dehiscence in these cases.

We describe a one-stage technique of levator and Muller’s muscle recession combined with a tarsorrhaphy usedin four patients with an impending corneal perforation due to cicatricial lagophthalmos.

Methods: This is an interventional, non-comparative retrospective case series of four patients who hadundergone tarsorrhaphy in combination with levator recession.

Results: In all four cases, it was not possible to mechanically close the eyelids preoperatively due to cicatricial lidretraction involving the middle lamella. The aetiology for lagophthalmos was varied: (Case 1) bilateralsclerosing metastatic breast cancer involving the lids; (Case 2) severe anterior and middle lamella shorteningdue to actinic changes; (Case 3) middle and posterior lamella shortening due to glaucoma treatment andmultiple surgery (Case 4) due to traumatic facial scarring and seventh nerve palsy. In all cases, the cornealthinning and epithelial defects resolved completely following surgery. In one case, we were able to partiallyreopen the tarsorrhaphy for further corneal surgery.

Discussion: We describe a safe, effective and reversible surgical procedure for managing cases with cicatricialupper eyelid retraction, which would otherwise lead to serious corneal complications.

Keywords: Cicatrix/surgery, corneal/pathology, epithelium, eyelid diseases/surgery, eyelids/surgery, surgicalmanagement, treatment outcome

INTRODUCTION

Lagophthalmos causing exposure keratopathy andimpending corneal perforation can result in devastat-ing consequences if not treated effectively andpromptly. Treatment includes ocular lubricants,eyelid taping, downward lid massage, botulinumtoxin, tarsorrhaphy, levator recession, upper lidweights, improving lateral canthal insertion, spacers,mid-face lifts, and temporalis muscle transposition.1,2

While paralytic and nocturnal lagophthalmos arehighly amenable to surgical treatment, the treatment

of cicatricial cases is challenging because of thetension keeping the lids open.3

We describe a technique that, in our experience,effectively treats corneal exposure due to cicatricialupper lid retraction using a combination of two well-known widely practised oculoplastic procedures.

MATERIALS AND METHODS

This is an interventional, non-comparative retro-spective case series of 4 patients with impending

Correspondence: Avinash Manna, University Hospital Coventry, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom. E-mail:amanna@doctors.org.uk

Received 5 August 2012; Revised 13 November 2012; Accepted 28 January 2013; Published online 5 April 2013

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corneal perforation due to cicatricial lagophthalmoswho had undergone tarsorrhaphy in combinationwith Levator-Muller’s recession.

Surgical Technique

The upper eyelid crease is marked and the skinand orbicularis are infiltrated with 2% lignocainewith 1:200 000 adrenaline along with supratarsalsubconjunctival infiltration after everting the lid.The skin crease incision is fashioned and upperborder of tarsus is exposed through the anteriorapproach. The levator aponeurosis is exposedand the Levator-Muller’s complex is max-imally recessed without the use of a spacer. Skinis closed with 7/0 polyglactin suture. Followingthis, standard tarsorrhaphy (using 6/0 polyglactinand 6/0 silk) is performed as part of thisprocedure.

CASE REPORTS

Case 1

A 64-year-old female with sclerosing metastatic breastcancer was referred for management of bilateralcorneal exposure due to full-thickness infiltration ofthe lids by metastatic disease causing lid shortening inall anatomical layers to some extent, and mostseverely affecting middle lamella. As the lids couldnot be mechanically apposed or everted preopera-tively, a lateral tarsorrhaphy was combined withLevator-Muller’s recession. The epithelial defect inboth eyes subsequently resolved.

Case 2

An 83-year-old female patient with history of previ-ous multiple left periocular skin grafts following

FIGURE 1. (A) (Case 3) - pre-op photo showing right lagophthalmos due to severe middle and posterior lamellar shortening.(B) (Case 3) - post-op photo following right medial canthoplasty, lateral tarsorrhaphy with Levator-Muller’s recession.

Surgical Management of Cicatricial Lagophthalmos 191

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excision of basal cell carcinomas and forehead radio-therapy presented with severe left corneal exposure.She had severe anterior and middle lamellar shorten-ing of the left upper lid due to severe actinic changes,skin graft related and associated middle lamellarcicatrisation. It was not possible to mechanicallyappose the lids and botulinum toxin only induced apartial ptosis. She underwent a lateral tarsorrhaphycombined with Levator-Muller’s recession followingwhich the corneal epithelial defect resolved.

Case 3

A 54-year-old male with high myopia who hadpreviously undergone trabeculectomy and wasaphakic following retinal detachment surgery pre-sented with right lagophthalmos due to severe middleand posterior lamellar shortening possibly related totopical glaucoma medication and previous ocular

surgery. This caused a right exposure keratopathy(Figure 1A) with a corneal leak for which he under-went amniotic membrane grafting with a Prokeralens. As mechanical apposition was not possible andbotulinum toxin had only induced a partial ptosis, heunderwent a right medial canthoplasty, lateral tarsor-rhaphy with Levator-Muller’s recession (Figure 1B). Amonth later the cornea had healed and the tarsor-rhaphy was partially opened to allow access andmonitoring for a subsequent tectonic corneal graft.

Case 4

A 50-year-old male presented with multiple facialinjuries following a road traffic accident. He hadextensive facial scarring, and a 7th nerve palsycausing corneal exposure in the right eye. Botulinumtoxin only induced a partial ptosis and two previousconventional tarsorrhaphies had dehisced (Figure 2A)

FIGURE 2. (A) (Case 4) – pre-op photo showing right lagophthalmos due to cicatrix causing middle lamellar shortening.(B) (Case 4) – post-op photo following right central tarsorrhaphy with Levator-Muller’s recession.

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possibly due to middle lamella shortening. Hence, arepeat central tarsorrhaphy was combined withLevator-Muller’s recession which resulted in effectiveand more permanent lid closure (Figure 2B). Theepithelial defect subsequently resolved.

DISCUSSION

We describe a safe, effective and reversible surgicalprocedure for managing cases of corneal exposurewith cicatricial upper lid retraction. The aetiology ofthe lagophthalmos in our cases was varied: all caseshad middle lamella shortening with or withoutanterior or posterior lamella involvement. Themiddle lamella consists of orbital septum, orbital fat,suborbicularis fibroadipose tissue and Levator-Muller’s complex (in the lower lid, this also includesthe lower lid retractors). In all cases, the epithelialdefects resolved completely following surgery.

We feel that this technique is indicated in cases ofcicatricial lagophthalmos where it is not possible tomechanically close the lids due to middle lamellashortening. Conventional tarsorrhaphy is likely todehisce and botulinum toxin or Levator-Muller’srecession alone is likely to only induce a partial ptosis.

Levator-Muller’s muscle disinsertion has beendescribed in cases of thyroid orbitopathy to improvelid retraction.4 Looi et al.5 reported the use ofrecessing Muller’s muscle and levator aponeurosisvia a posterior approach, occasionally including atemporal tarsorrhaphy, to treat upper eyelid retraction

in patients with symptomatic Graves orbitopathy. Wefeel that the posterior approach is an alternative incases with evertable upper lids with middle lamellashortening.

In cases where the cornea is at risk of perforation,an effective procedure is needed. Our techniquewould be best suited for patients with cicatricial lidretraction where the middle lamella is thought to bethe possible target, especially in cases where thecornea is at risk of perforation.

DECLARATION OF INTEREST

The authors report no conflicts of interest. The authorsalone are responsible for the content and writing ofthe paper.

REFERENCES

1. Pereira MVC, Gloria ALF. Lagophthalmos. SeminOphthalmol 2010;25(3):72–78.

2. Rahman I, Sadiq S. Ophthalmic management of facialnerve palsy: a review. Surv Ophthalmol 2007;52(2):121–144.

3. Han S, Ock JJ. Treatment of cicatricial lagophthalmos: verysmall orbicularis oculi muscle pedicled skin flap. Br J PlastSurg 2001;54(8):675–679.

4. Mourits MP, Sasim IV. A single technique to correct variousdegrees of upper lid retraction in patients with Graves’orbitopathy. Br J Ophthalmol 1999;83(1):81–84.

5. Looi ALG, Sharma B, Dolman PJ. A modified posteriorapproach for upper eyelid retraction. Ophthal Plast ReconstrSurg 2006;22(6):434–437.

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