“I can see!!!”

“I can see!”

That was the greeting I got from our 90+ year old postoperative patient last Friday.  She had previously be unable to do the things that she really enjoyed, like knitting and crafts, because of her upper lid ptosis.

Her problem was particularly challenging, surgically, for a number of reasons:  

1. She was severely ptotic, with the resting position of the upper lids completely blocking the pupils.

2. She had lids that were detached from the bone at the lateral canthus (outer corner of the eyelids).

3. She had somewhat sunken eyes from age-related bony and soft tissue changes of the eye sockets.

 

A preoperative photo is presented below:

The challenge in correcting this condition is that simple ptosis repair would risk the inability of the eyes to close due to lack of a “counter pull”  — the detached outer eyelid ligaments would not allow the lids to snap closed.  This canthal dehiscence (detachment of the outer corners of the eyelids from the bone) can be due to prior cosmetic surgery, or can simply be age-related.  The treatment is a canthoplasty.

The problem with canthoplasty in this patient is the geometry of the eye socket (the relative position of the eye to the bony rim of the socket).  Since the eye was a little sunken, suturing the lids to the edge of the bony rim could tighten the lid, but unfortunately the lid would be pulled away from the eyeball at the outside corner.  This is because the bony rim is IN FRONT OF the eyeball there (remember, the eyeball is sunken).  It is impossible to suture the lid to the bone in any standard way without the lid being pulled away from the eyeball.  

In order to make a deeper attachment point on the bone, a drill hole is required.  This drill hole canthoplasty then allows the lids to be attached to the bone at a more posterior vector, so that the lid attachments can be restored while keeping the lid snug against the eyeball.

The other complexity of the procedure is that, when tightening the eyelid against the bone, the natural tendency is to make the eyelids sit even lower than they start — it can worsen ptosis.  So, in this patient, I had to walk a tightrope:  

1. Tighten the lids against the bone, using a drill hole to achieve the proper vector, at the proper tension so that the lid closes but not too tight such that the ptosis worsens.

2. Actually treat the ptosis with a central lid incision and a tightening of the central lifting muscle of the eyelid (the levator muscle).

3. Manage the interaction of these two procedures such that the tightened, lifted lid has a natural contour with a lid peak centered over the pupil.  One can imagine that if the upper lid height is set and the lid is lifted, but then the lid is stretched and tightened horizontally with the canthoplasty, it could disrupt the desired upper eyelid curvature.

I am pleased to say that we succeeded on all measures at the one week postoperative visit.  The shape, height, symmetry, and closure were all excellent.  And as proof of a successful outcome, my patient presented me with a poem, and a gift that she had made for me: