David R. Fett

Müller's muscle in the treatment of upper eyelid ptosis: a ten-year study.

Müllers muscle is a sympathetically innervated muscle that can be resected to treat upper eyelid ptosis. Candidates for the ptosis procedure are those whose upper lids elevate to a normal level following instillation of phenylephrine hydrochloride drops into their upper ocular fornix. A specially designed clamp is applied to 6.5 to 9.5 mm of conjunctiva and Müllers muscle above the superior tarsal border. A suture is run distal to the clamp, connecting conjunctiva and Müllers muscle to the superior tarsal border; then, the tissues held in the clamp are resected. In a ten-year study of this procedure, 90% of the lids with acquired ptosis and 100% of those with congenital ptosis were within 1.5 mm of the level of the opposite lid postoperatively. Only two of 232 treated lids required additional surgery.

Conjunctiva-Muller's muscle excision to correct anophthalmic ptosis

We treated 35 eyelids with ptosis and anophthalmos by resecting conjunctiva and Müllers muscle. Before surgical intervention all patients were evaluated by an experienced ocularist who, if necessary, modified or refit the prosthesis. All eyelids had a positive response to 10% phenylephrine hydrochloride. Preoperatively, the margin reflex distance-one (MRD-1) of the ptotic eyelids ranged from -2.0 to +3.5 mm. The amount of conjunctiva-Müllers muscle excision ranged from 7.25 to 9.25 mm. Following surgery, the average change in MRD-1 was 3.33 mm. Thirty-one eyelids (88.6%) achieved a post-operative level within 1 mm of the opposite eyelid. There were two overcorrections and two undercorrections. Postoperatively, no patients had any compromise of the superior fornix, socket dryness, or inability to retain their prosthesis. Resection of conjunctiva and Müllers muscle is a simple and effective method to treat ptosis associated with anophthalmos.

Müller's Muscle in the Treatment of Upper Eyelid Retraction: A 12-Year Study

Müllers muscle is a sympathetically innervated muscle that can be excised to relieve upper eyelid retraction. A graded, controlled excision of Müllers muscle, with or without recession of the levator aponeurosis, using sensory without motor anesthesia is an excellent technique for releasing thyroid-related upper eyelid retraction. The procedure is simple, based on anatomic and physiologic principles, tailored to the individual patient intraoperatively, and yields consistently good results. In a 12-year study of this procedure, 96% of the treated lids attained lid levels within 1.5 mm of the opposite side. Only seven of 156 treated eyelids required additional surgery.

Bleeding in cosmetic blepharoplasty: an anatomical approach.

The complication of bleeding associated with cosmetic blepharoplasty was investigated by dissection of two freshfrozen cadaver heads. The arteries were injected with Neoprene latex and dissection of the tissues encountered in blepharoplasty surgery was performed. From the study, three major components of the orbital and eyelid vascular system were felt to be important. These consisted of the individual tissue vascularity, the major arterial trunks in the region, and the connective tissue support of the arteries. Conclusions are reached regarding the prevention of bleeding associated with cosmetic blepharoplasty.

Muller's Muscle-conjunctival Resection Procedure in the Treatment of Ptosis in Horner's Syndrome

The predictability of the phenylephrine test and the efficacy of the Mullers muscle-conjunctival resection procedure in the management of blepharoptosis in six cases of Horners syndrome were assessed. Before phenylephrine testing or surgery, an average of 2.3 mm of ptosis was present. Topical phenylephrine elevated upper lids an average of 2.2 mm. The amount of elevation produced by the phenylephrine guided the amount of Mullers muscle and conjunctiva resected. Postoperative upper lid levels were exactly symmetrical in five of six patients. In one patient the previously ptotic lid was 0.5 mm higher than the contralateral lid. Even though Mullers muscle is rendered nonfunctional in Horners syndrome by denervation, the Mullers muscle-conjunctival resection procedure proved to be a very effective method of treating ptosis in this setting. Our findings imply that the mechanism by which this procedure alleviates ptosis is independent of active contraction of Mullers muscle.

Comparison of 2.5% and 10% Phenylephrine in the Elevation of Upper Eyelids with Ptosis

The Muellers muscle-conjunctival resection procedure has been effective in treating ptosis in eyelids that elevate upon instillation of topical 10% phenylephrine (Neo-Synephrine). The small risk of an adverse systemic reaction to phenylephrine could be even further decreased by using 2.5% phenylephrine instead of 10% phenylephrine. In order to assess the feasibility of using 2.5% phenylephrine instead of 10% phenylephrine in ptosis evaluation, we compared the amount of upper eyelid elevation produced by the two solutions. Thirty ptotic upper eyelids in 20 patients exposed to 10% phenylephrine rose an average of 0.2 mm higher than the same lids exposed to 2.5% phenylephrine. Although this difference was statistically significant, we suspect that the small magnitude of this difference would have little effect on the decision to perform a Muellers muscle-conjunctival resection procedure or on the calculation of the amount of tissue to resect.

Evaluation of lubricants for the prosthetic eye wearer

We evaluated the need for additional lubrication in 200 consecutive patients using an ocular prosthesis. Of these patients, 154 (77%) required no additional lubrication, while 46 patients (23%) required supplemental lubrication. Enuclene, the only product manufactured specifically for the patient with an ocular prosthesis, has been reported by the majority of our patients to be inadequate for comfort and wearability. Other solutions for contact lens use were compared with Enuclene and found to be far superior by patients using an ocular prosthesis.