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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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Year : 2021  |  Volume : 28  |  Issue : 4  |  Page : 216-220  

Outcomes of posterior approach surgery in various types and grades of upper eyelid blepharoptosis in Indian eyes

1 Ophthalmic Plastic Services, Indira Gandhi Eye Hospital, Lucknow, Uttar Pradesh, India
2 Centre for Ocular Regeneration, LV Prasad Eye Institute, Hyderabad, Telangana, India

Date of Submission28-Oct-2020
Date of Acceptance24-Mar-2022
Date of Web Publication30-Apr-2022

Correspondence Address:
Dr. Nidhi Pandey
Indira Gandhi Eye Hospital, 1 B. N. Road, Qaiserbagh, Lucknow - 226 010, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/meajo.meajo_472_20

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PURPOSE: To present the outcomes of levator plication (levatorpexy) surgery by posterior approach for correction of ptosis of different aetiologies in Indian eyes.
METHODS: Retrospective review of clinical notes and clinical photos of consecutive ptosis patients who underwent levatorpexy from January 2017 to September 2018. Surgery was considered successful if the following four criteria were simultaneously met: a postoperative MRD1 of ≥2 mm and ≤4.5 mm, inter eyelid height asymmetry of ≤1 mm, no overcorrection compared to the opposite eye, and a satisfactory eyelid contour determined by patient.
RESULTS: Thirty six eyelids of 36 patients (mean age, 23.6 years; 25 females) underwent unilateral levatorpexy with the left eyelid affected in 66.6 %. Twenty one congenital (58.3%) (C), 12 (33.3%) aponeurotic (A) and 3 (8.3%) complex ptosis (CX) had a mean levator function of 9.8 mm (range, 6 to 15). Mean pre and post operative margin reflex distance (MRD 1) was 0.611mm (range, -1 to 3 mm) and 3.00 mm (range, 2 to 4 mm) respectively. At the final follow up of 12 months, four patients remained under corrected (11.1%). At the final follow up of twelve months, the success rate was 78 percent.
CONCLUSION: Posterior approach for ptosis repair offers a scar less, minimally invasive, easy to revise, and successful lid height correction in congenital and acquired ptosis.

Keywords: Levatorpexy, posterior approach, ptosis

How to cite this article:
Pandey N, Singh S. Outcomes of posterior approach surgery in various types and grades of upper eyelid blepharoptosis in Indian eyes. Middle East Afr J Ophthalmol 2021;28:216-20

How to cite this URL:
Pandey N, Singh S. Outcomes of posterior approach surgery in various types and grades of upper eyelid blepharoptosis in Indian eyes. Middle East Afr J Ophthalmol [serial online] 2021 [cited 2022 Aug 19];28:216-20. Available from: http://www.meajo.org/text.asp?2021/28/4/216/344448

   Introduction Top

Posterior approach ptosis repair, first described by Blaskovicz in 1923 for congenital ptosis, involved levator muscle resection with tarsectomy.[1] In 1953, Berke further simplified Blaskovics' technique by avoiding tarsal excision.[2] Following this, most studies described a posterior approach for mild ptosis with excision of tarsal tissue and/or Muller's muscle with the conjunctiva.[3],[4],[5],[6],[7],[8],[9] Patel et al. in 2010 described a technique of plicating the levator aponeurosis through a conjunctival incision without any tissue excision and breach of the septum for the correction of aponeurotic ptosis, achieving a success rate of 87.3%.[10] Al-Abbadi et al. later described a modification of the same procedure for congenital ptosis correction, where plicating sutures were placed higher up into the Levator palpebrae superioris (LPS), the “levatorpexy” technique achieving a success rate of 87%.[11] Five published articles from a single-center describe levator plication through posterior approach (levatorpexy) for congenital and aponeurotic ptosis of various grades.[10],[11],[12],[13],[14] We describe our experience using the levatorpexy technique for upper eyelid ptosis of various grades and etiologies in Indian eyes.

   Methods Top

The study was a retrospective review of clinical notes and photographs of 36 consecutive cases of upper eyelid ptosis who underwent levatorpexy. All surgeries were performed by a single surgeon (N. P). Written informed consent was obtained from all the patients. The study was conducted in accordance with the tenets of the Declaration of Helsinki and approved by the Institutional Ethics Committee. Evaluated data included medical history, visual acuity, upper eyelid margin reflex distance (MRD1), levator function (LF), Schirmer test (without topical anesthesia), and ocular motility assessment. MRD1 was measured as the distance in millimeters (mm) from the light reflex on the patient's cornea to the central segment of the upper eyelid margin while the patient looks in the primary position. A phenylephrine test (PT) (2.5%) was also performed at the time of consultation and an increase of MRD1 >1 mm after 10 min of drop instillation was interpreted as “phenylephrine positive.”[10] All patients were photographed at every visit. Studied outcome parameters were preoperative and postoperative MRD1, change in MRD 1, symmetry of height, and lid contour. Surgical success was labeled when all the four criteria were met simultaneously: A postoperative MRD 1 of ≥2 mm and ≤4.5 mm, inter eyelid height asymmetry of ≤1 mm, no sign of overcorrection compared to the opposite eye, and satisfactory eyelid contour as assessed by the patient subjectively. Patients with synkinetic ptosis and those with LPS action <4 mm and follow-up of <1 year were excluded from the study.

Surgical procedure

All cases except one were performed under local anesthesia. Lignocaine (2%) with 1: 80,000 adrenaline is injected subcutaneously along the upper eyelid skin crease and in the pretarsal region and subconjunctival infiltration (0.5 mL) superior to the tarsal plate [Figure 1]a. A 4-0 silk traction suture is placed along the gray line of the upper eyelid and everted over a Desmarres retractor. To destroy epithelial cells, gentle diathermy is applied to the conjunctiva immediately above and at the superior tarsal border. A conjunctival incision is made with a no. 11 Bard-parker blade along the conjunctiva immediately distal to the superior tarsal border [Figure 1]b. Muller's muscle and conjunctiva are dissected off as a composite flap until the white line representing the posterior border of the levator aponeurosis can be identified [Figure 1]c.
Figure 1: (a) Local anesthetic injection (b) conjunctival incision was made with a no. 11 Bard-parker blade along the conjunctiva immediately distal to the superior border of the tarsus (c) Muller's muscle and conjunctiva dissected off as a composite flap (d) double armed 6-0 absorb-able suture was placed placed at a point in vertical line with the central peak of the tarsal plate, through the posterior surface of the Levator muscle (e) The needle exteriorized at or below the skin crease

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Dissection was then continued between the posterior surface of the levator aponeurosis and the conjunctiva to expose the posterior surface of the levator muscle. A double-armed 6-0 Vicryl suture is placed at a point in a vertical line with the central peak of the tarsal plate, through the posterior surface of the levator muscle, approximately 1 mm from the superior edge of the levator aponeurosis in a forehand manner [Figure 1]d. The needle is passed twice, taking care to capture the levator muscle's thin, partial-thickness bite. The needle track is <1 mm below the superior tarsal border on the conjunctival side and exteriorized at or below the skin crease [Figure 1]e. After making the loop knot, lid contour and height are assessed. The suture can be placed further up or below the initial pass to achieve desired height and contour. In the only case done under general anesthesia, the sutures were placed 1 mm from the superior edge of levator aponeurosis. Before tying the first suture, the second set of sutures is placed in the same manner, 2 mm lateral or medial to the first suture (guided by lid contour assessment during surgery). The absorbable sutures were left in situ. Muller's muscle and conjunctiva were left to heal spontaneously with no excision or suturing of these structures. A narrated video of the technique is included as a supplementary file [Video 1].

   Results Top

Thirty-six eyelids of 36 consecutive patients who underwent levatorpexy procedure from January 2017 to September 2018 were included. The mean age was 23.6 years (range, 7–79) of 25 females (69.4%) and 11 males (30.5%). Twenty-one patients had congenital ptosis (58.3%), 12 had aponeurotic (33.33%), and three had complex (8.33%) ptosis (monocular elevation deficit or neurogenic ptosis), affecting 24 (66.66%) left and 12 (33.33%) right eyelids. Two patients had undergone levator resection in the past. The mean LF was 9.8 mm (range, 6–15 mm). The mean pre-and-post MRD 1 was 0.61 mm (median, 1; range, −2–3 mm) and 3 mm (median, 3; range, 1–4 mm). The overall mean change in the lid height was 2.27 mm (median, 2; range, 0–4.5 mm). At the final follow-up of 1 year, 28 (78%) patients met all four defined criteria of a successful outcome in our study [Figure 2]. Two patients (5.5%) had complex ptosis associated with residual monocular elevation defect (MED) after strabismus surgery and were left under corrected to protect the ocular surface [Figure 3]. Etiology-wise comparison of results is presented in [Table 1].
Figure 2: Preoperative (a-c) and postoperative (d-f) photos of left eye mild, moderate, and severe ptosis, respectively

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Figure 3: Preoperative (a and b) and postoperative (c and d) photos of a case of the left eye ptosis in monocular elevation deficit corrected by levator plication

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Table 1: Etiology-wise comparison of outcomes

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Ten patients (27.7%) had under correction at 1 week, defined as MRD 1 ≤2 mm. One patient developed suture site infection resulting in under correction but achieved symmetrical lid height after resolution of infection with conservative management. Two patients spontaneously achieved good MRD 1 values at 1 month and final follow-up at 12 months [Figure 4]. Three patients underwent repeat procedures, two levatorpexy and one anterior approach levator resection, achieving symmetrical lid height at final follow-up [Figure 5]. The resurgery rate at the end of 1 year was 8.3%. Four patients remained under-corrected at the final follow-up of 12 months (11.1%). These four patients had an LPS action of 5 mm. None of these patients opted for a second procedure as they were satisfied with the lid contour and the absence of gross asymmetry between the eyelids.
Figure 4: Spontaneous improvement of residual ptosis showing (a) preoperative, (b) 3-month follow-up with residual mild ptosis left eye, and (c) symmetrical lid height at 1-year follow-up

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Figure 5: (a) Preoperative left eye severe congenital ptosis, (b) residual ptosis at 3-month follow-up (c) postrepeat levatorpexy at 6-month follow-up with symmetrical lid height

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PT was positive in 14 patients (38.8%). The mean postoperative MRD 1 and lid height change was 3.5 mm (range, 2 mm to 5 mm) and 2.5 mm (range, 0 mm to 4 mm), respectively, in the PT-positive group with a success rate of 78%. PT-negative group had a success rate of 71.4% with a mean postoperative MRD 1 of 2.54 mm (range, 1 mm to 4 mm) and lid height change of 2.12 mm (range 0 mm to 4.5 mm) (Mann–Whitney U test; P = 0.004).

   Discussion Top

We describe our experience of the levatorpexy technique for ptosis correction in three different types of ptosis. The results of our study substantiate the effectiveness of levatorpexy as a minimally invasive method of correcting ptosis of mild-to-severe degrees with fair to good LF in both congenital and aponeurotic varieties. A PT is a valuable tool in predicting postoperative lid height and inner eyelid symmetry. The postoperative outcomes were better in PT-positive cases in our series, similar to previous studies, although unlike Müller muscle-conjunctiva resection (MMCR), a negative PT result is not a contraindication for this surgery.

Ng et al.[15] described levator plication through vertical conjunctival incision extending up to fornix and dissecting LPS from the anterior surface of tarsus before plicating it for aponeurotic ptosis. They reported a success rate of 86.4%. Patients with LPS action below 6 mm were excluded. Ichinose and Tahara[16] reported a technique of levator advancement through an incision of conjunctiva and Muller's muscle horizontally along with medial two-thirds of the superior border of the tarsus. Similar to Collin's approach, their technique required an incision of the orbital septum to expose the anterior surface of the levator before advancing it to the front-superior part of the tarsal plate. Our technique did not dissect the orbital septum or require a vertical incision. The “white line advancement” for aponeurotic ptosis and “levatorpexy” for congenital cases achieved results similar to either anterior or posterior approach of levator resection/plication and MMCR in correcting ptosis of a wide range of severity and LF. There was minimal handling of delicate posterior lamella structures such as conjunctiva and Muller's. Hence, there was no compromise of the ocular surface, which has been a concern in some studies criticizing the posterior approach.[17] The posterior surface of LPS which contains more smooth muscle fibers was effectively advanced in levatorpexy, minimizing the chances of erroneously plicating the septum to the tarsus.[18] The final success rate in our series was 78%. A mixed etiology of ptosis with a wide disparity in preoperative lid height and LPS action led to a comparatively lower success rate.

However, the final MRD 1 and mean change in MRD 1 values in aponeurotic and congenital cases are comparable to the previous series [Table 2].[10],[11],[12],[13],[14] Feldman et al.[12] recently reported a modification of levatorpexy in their series of 16 consecutive congenital ptosis cases. They suggested an algorithm for deciding the height of suture placement in LPS based on LF and PT results. Keeping the same criteria as their previous series of levatorpexy, the success rate was 87.5%. This modification was not adopted in our series. This can partially explain lower mean postoperative MRD 1 values in congenital ptosis and the residual ptosis in four cases with 5 mm LPS action in our series. Our study includes two cases of monocular elevation deficit and one case of old, third nerve palsy post strabismus. Our experience with these three cases was encouraging. The primary aim of clearing the visual axis while protecting ocular surface exposure (due to restricted upgaze) is accomplished with a minimally invasive procedure and patient satisfaction. An exclusive case series using levatorpexy for complicated, myogenic, and neurogenic ptosis, detailed ptosis-specific outcome analysis, and patient satisfaction can provide evidence for recommending posterior approach ptosis correction. The limitation of the study is the retrospective nature and unavailability of outcomes for cases requiring general anesthesia for congenital ptosis.
Table 2: Comparison of outcomes of the present study with published literature

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   Conclusion Top

Our study reports the levatorpexy outcomes in congenital, aponeurotic, and complex ptosis where a good lid height and contour was achieved in 78 percent of patients with no significant ocular surface complication and resurgery rates. A prospective series with a comparable number of cases of each etiology will give us better insights into the effectiveness of posterior approach levator plication over a wide range of ptosis degrees and types.


The authors would like to acknowledge Dr. Kumar Saurabh from Kolkata for his valuable inputs during manuscript preparation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Blaskovicz L. A new operation for ptosis with shortening of the levator and tarsus. Arch Ophthalmol 1923;52:563-73.  Back to cited text no. 1
Berke RN. A simplified Blaskovics operation for blepharoptosis; results in ninety-one operations. AMA Arch Ophthalmol 1952;48:460-95.  Back to cited text no. 2
Putterman AM, Urist MJ. Müller muscle-conjunctiva resection. Technique for treatment of blepharoptosis. Arch Ophthalmol 1975;93:619-23.  Back to cited text no. 3
Putterman AM, Fett DR. Müller's muscle in the treatment of upper eyelid ptosis: A ten-year study. Ophthalmic Surg 1986;17:354-60.  Back to cited text no. 4
Lake S, Mohammad-Ali FH, Khooshabeh R. Open sky Müller's muscle-conjunctiva resection for ptosis surgery. Eye (Lond) 2003;17:1008-12.  Back to cited text no. 5
Dresner SC. Further modifications of the Müller's muscle-conjunctival resection procedure for blepharoptosis. Ophthalmic Plast Reconstr Surg 1991;7:114-22.  Back to cited text no. 6
Maheshwari R, Maheshwari S. Muller's muscle resection for ptosis and relationship with levator and Muller's muscle function. Orbit 2011;30:150-3.  Back to cited text no. 7
Mazow ML, Shulkin ZA. Mueller's muscle-conjunctival resection in the treatment of congenital ptosis. Ophthalmic Plast Reconstr Surg 2011;27:311-2.  Back to cited text no. 8
Collin JR. A ptosis repair of aponeurotic defects by the posterior approach. Br J Ophthalmol 1979;63:586-90.  Back to cited text no. 9
Patel V, Salam A, Malhotra R. Posterior approach white line advancement ptosis repair: The evolving posterior approach to ptosis surgery. Br J Ophthalmol 2010;94:1513-8.  Back to cited text no. 10
Al-Abbadi Z, Sagili S, Malhotra R. Outcomes of posterior-approach 'levatorpexy' in congenital ptosis repair. Br J Ophthalmol 2014;98:1686-90.  Back to cited text no. 11
Feldman I, Brusasco L, Malhotra R. Improving outcomes of posterior approach levatorpexy for congenital ptosis with reduced levator function. Ophthalmic Plast Reconstr Surg 2018;34:460-2.  Back to cited text no. 12
Antus Z, Salam A, Horvath E, Malhotra R. Outcomes for severe aponeurotic ptosis using posterior approach white-line advancement ptosis surgery. Eye (Lond) 2018;32:81-6.  Back to cited text no. 13
Malhotra R, Salam A. Outcomes of adult aponeurotic ptosis repair under general anaesthesia by a posterior approach white-line levator advancement. Orbit 2012;31:7-12.  Back to cited text no. 14
Ng DS, Chan E, Ko ST. Minimally invasive internal ptosis surgery. Eye 2015;29:483-91.  Back to cited text no. 15
Ichinose A, Tahara S. Transconjunctival levator aponeurotic repair without resection of Müller's muscle. Aesthetic Plast Surg 2007;31:279-84.  Back to cited text no. 16
Andersen RL. Predictable ptosis procedures: Do not go to the dark side. Ophthalmic Plast Reconstr Surg 28:239-41.  Back to cited text no. 17
Kakizaki H, Zako M, Nakano T, Asamoto K, Miyaishi O, Iwaki M. The levator aponeurosis consists of two layers that include smooth muscle. Ophthalmic Plast Reconstr Surg 2005;21:379-82.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2]


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