Ptosis Due to Levator Disinsertion: A Specific Entity

Abstract

Introduction:

The purpose of this study is to clarify that ptosis due to levator disinsertion (traumatic) is a distinct entity from levator dehiscence (involutional).

Materials and Methods:

This was a prospective study of 12 consecutive cases of levator disinsertion seen in the oculoplastic department of a tertiary referral center between October 2009 and June 2012. There were 5 men and 6 women, one of whom had bilateral ptosis. Their ages ranged between 57 and 64 years in 11 cases; the 12th case was a 20-year-old woman. Eleven cases had had cataract surgery 6 months to 2 years previously while the 20-year-old woman developed sudden ptosis after rubbing her eye because of vernal keratoconjunctivitis. All had severe to total ptosis with very poor levator function (<4.0 mm) and a margin reflex distance 1 (MRD1) between −2.0 mm to −4.0 mm. They were managed by levator reinsertion performed by a single surgeon (S.I.) and followed up at 1 week, 1 month, and 6 months postoperatively.

Results:

Intraoperatively, the levator aponeurosis was found detached from the tarsal plate and retracted high up in the upper fornix. Postoperatively, the patients had good cosmesis with symmetrical palpebral aperture heights of 9.0–9.5 mm, MRD1 of 4.0–5.0 mm, and symmetrical upper lid creases. There was no recurrence of ptosis in any patient.

Conclusions:

This study highlights the fact that levator disinsertion is a specific clinical entity. All of the patients presented with severe ptosis and a very poor to absent levator function. This situation should not entice a surgeon to perform a brow suspension, however; the patients simply need a levator reinsertion without a levator resection.