ophthalmopathy: a new surgical abnormal levator muscle

69 Pages·2005·18.32 MB·English

UPPER EYELID RETRACTION IN GRAVES'
OPHTHALMOPATHY: A NEW SURGICAL
TECHNIQUE AND A STUDY OF THE
ABNORMAL LEVATOR MUSCLE*
BY Robert G. Small, MD
INTRODUCTION
EYELID RETRACTION IN GRAVES' OPHTHALMOPATHY PRODUCES THE CHAR-
acteristicwide-eyed, staringappearance associatedwithincompleteeyelid
closure and exposure keratoconjunctivitis.
This thesis describes a new surgical operation to correct upper eyelid
retraction. The technique used is unique in that the levator muscle is
completely divided in the superior orbit proximal to Whitnall's ligament
and positioned with sutures that permit postoperative adjustment. (Cur-
rent surgical procedures for recession ofthe retracted upper eyelid in-
volved the aponeurosis of the levator muscle rather than its proximal
muscular portion.)
A surgical and histologic study of the new procedure in cynomolgus
monkeysisdescribed, followedbyanaccountoftheclinicalexperienceina
series ofpatients.
This thesis also describes for the first time the gross and microscopic
anatomyofthe abnormal proximal levator muscle in Graves' ophthalmop-
athy. Previous descriptions of the extraocular muscles in Graves' eye
disease are directed primarily to the oculorotatory muscles or the levator
aponeurosis.
Four thousand computer-assisted muscle fiber measurements in abnor-
mal and control levator muscle specimens are reported. These measure-
ments show for the first time that enlargement ofthe levator muscle in
Graves' ophthalmopathy is associated with increased muscle fiber size.
These findings have important implications for our understanding ofthe
pathogenesis ofupper eyelid retraction in Graves' ophthalmopathy.
*FromtheDeanA. McGeeEyeInstituteandtheDepartmentofOphthalmology, University
ofOklahomaHealthSciencesCenter, OklahomaCity, Oklahoma.
726 Small
TERMINOLOGYANDCLASSIFICATION
The terms Graves' ophthalmopathy, Graves' eye disease, and ophthalmic
Graves' disease refer to the characteristic changes in the eyelid, the orbit
and the extraocular muscles that accompany or follow hyperthyroidism.
These changes are also occasionally found in patients who show no evi-
dence ofpre-existing thyroid disease (euthyroid Graves' disease).'
Eyelid retraction is present in almost allpatients with Graves' ophthal-
mopathy.2 This class I change ofthe American ThyroidAssociation classi-
fication3'4 is often associated with more severe manifestations: proptosis,
diplopia, corneal decompensation, congestive ophthalmopathy and visual
loss. Althoughthesemoreseverecomplicationshavepriorityintreatment,
in the author's series upper eyelid retraction is the sequela ofGraves' eye
disease most often treated surgically (Table I).
Although lower eyelid retraction is an important component ofGraves'
ophthalmopathyand often requires surgical correction, itis not discussed
here. The term eyelid in this thesis refers to the upper eyelid.
MATERIALSANDMETHODS
PATIENTSERIES
Sixty-eight patients with Graves' ophthalmopathy were referred to the
author for surgery between 1979 and 1986. Ofthese, 46 had surgery for
upper eyelid retraction (Table I).
Twenty-five eyelids in 14ofthe46patients with uppereyelid retraction
were recessed with a new procedured called the proximal levator tech-
nique, in which the levator muscle proximal to Whitnall's ligament is
divided and fixed with a suture that permits postoperative adjustment of
eyelidposition. Thisnewprocedurealsoprovidesanopportunitytoobtain
biopsies ofthe abnormal levator muscle.
MEASUREMENTOFUPPEREYELIDPOSITION
Upper eyelid position varies from moment to moment depending on
alertness, attention, and emotional lability. To minimize this variation,
measurements are done with the patient in repose and fixatingatarget so
that the eyes are in the primary position with reference to the observer.
Measurements, photographs, and sketches recordthepreoperative eyelid
position.
Uppereyelidposition isrecordedintermsofthedistance inmillimeters
from thecenterofthepupiltothe edge ofthe uppereyelid. Thecenterof
the pupil seen by the examiner is close to the center of the cornea.5
Levator Muscle Surgery 727
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728 Small
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Levator Muscle Surgery 729
Measurements aretothe nearest0.5mm. Theverticallidfissuremeasure-
mentisnotusedhere, sinceitreflectsthepositionofbothupperandlower
eyelids.
Normal UpperEyelid Position
The mean distance between the normal upper eyelid and the midpupil is
3.5mmwithavariationof1.0mm.6Insomenormalpatientstheeyelidmay
behigher. Forexample, inyouththeuppereyelidcanbe5.5mmabovethe
center ofthe cornea (at the upper limbus) without being retracted.
UpperEyelid Retraction
Inpatients with Graves' eyedisease the mean distancebetween the upper
eyelid and the midpupil is 5.0 mm.6 In most Graves' ophthalmopathy
patientswhoarecandidatesforanuppereyelidrecessionprocedure, sclera
isvisibleabovethecorneallimbus(scleral show). Seleralshowoccurswhen
the upper eyelid is 6.0 mm or more above the midpupil.
INDICATIONFORRECESSIONOFTHEUPPEREYELIDINGRAVES'OPHTHALMIOPATHY
Patients with upper eyelid retraction complain of an abnormal staring
appearance, difficult eyelid closure, sleepingwith the eyes open, and dry
irritated eyes. These symptoms with keratoconjunctivitis and adecreased
Schirmer test are an indication for surgery.
SURGERYFORUPPEREYELIDRETRACTION
The techniques for upper eyelid retraction currently in use are:
1. Section or excision ofMluller's muscle.
2. Section or weakening ofthe levator aponeurosis with or without the
use ofscleraor cartilage.
3. Lateral tarsorrhaphy.
Table IIisaselectedchronologicallistoftechniquesforcorrectingupper
eyelid retraction in thyroid ophthalmopathy.7-18
Problems in Surgery
The number ofsurgical techniques for upper eyelid recession in Graves'
ophthalmopathy suggests the difficulty of this surgery. No surgical pro-
cedure has been generally adopted, and reoperations are not uncom-
mon.7-18 Wallerl8 suggests that a combination oftechniques be used. An
important source of difficulty is that surgery is carried out on diseased
tissues and has no effect on the disease process.'9 Ophthalmopathy pro-
gresses in some patients. Hering's law may lead to upper eyelid asvmme-
try.20-22
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TABLEII: TECHNIQUES FORCORRECTION OFUPPEREYELID RETRACTION IN GRAVES' EYE DISEASE
AUTHOR YEAR CONTRIBUTION
Goldstein7 1923 Early description oflevator reces-
sion
Berke8 1959 "Tenotomy"
Henderson9 1965 Muller's muscle myotomv with le-
vatorweakening
Crawford10 1967 Marginalmyotomyoflevator
Quickert" 1971 First suggestion that sclera to be
usedineyelidsurgery
Schimek12 1972 Combined procedures; "block re-
cession"oflevator
Dryden13 1977 Useofsclera
Chaflin14 1979 Muller'smuscleexcisionwithintra-
operativegradedrecessionofthe
levatoraponeurosis
Flanagan15 1980 Useofsclera; experimental studies
in rabbits
Harvey'6 1981 "Aponeurotic approach" to levator
recession
Dixon17 1982 ExcisionofMuller'smusclewithre-
insertion of the levator apo-
neurosisonconjunctivaortarsus
Waller18 1982 Mullerectomy; levator recession
combinedwithothertechniques;
detailedstudyofresultsandcom-
plications
SCLERAINSURGERYFOREYELIDRETRACTION
The placement of sclera as a "spacer" placed between the tarsus and
recessed levator aponeurosis has been widely investigated.13'23-25 How-
ever, the eyelid with a scleral graft may become chronically swollen and
uncomfortable.24 Recent reports suggest sclera is now used less fre-
quently.16-18
The Iliffs26placeascleralgrafthighin theeyelidjustdistaltoWhitnall's
ligament. This technique is similar to the proximal levator technique
described in this thesis in that the levator muscle is completely divided
close to Whitnall's ligament. Soll27 has used Iliff's technique successfully.
ORIGINALADJUSTABLESUTURETECHNIQUE
Onemethodofcorrectinguppereyelid retractionin Graves' eyedisease is
surgical weakening of the levator aponeurosis and Muller's muscle and
periodically placing the locally anesthetizedpatient in the sittingposition
during surgery to gauge the amount of levator recession achieved.'4
During one such procedure, I placed polypropylene sutures through the
LevatorMuscle Surgery 731
completely disinserted levator aponeurosis to support the eyelid in its
recessedposition, bothtoavoidovercorrectionandtopermitpostoperative
adjustment of upper eyelid position. Although adjustable sutures have
been used in strabismus surgery28-30 and in frontalis eyelid suspension,31
theiruseinthelevatoraponeurosistocontroleyelidpositionaftersurgery
was new. This procedure for upper eyelid retraction from any cause
including Graves' eye disease was published in 1982.32
The operation is performed through the conjunctiva with the eyelid
everted over a Desmarres retractor. The conjunctiva is dissected off
Muller's muscle, Muller's muscle is excised, andthelevatoraponeurosis is
cut from its tarsal, medial, and lateral attachments. Two monofilament
polypropylene mattress sutures hold the recessed levator in position and
are passed through the skin for later adjustment. A silk traction suture is
placedintheedgeoftheeyelid. Anillustrationfromthepapershowingthe
adjustable sutures in place is reproduced in Fig 1.
Thirty-nineeyelidsin21patientswithGraves'ophthalmopathywerere-
cessed by the original levator aponeurosis adjustable suture technique.
Two patients, because ofprogression oftheir ophthalmopathy, required
reoperation longafterthe original procedure. Theneedforreoperation in
thesepatientswas relatedtothediseaseprocess. Amongtheremaining35
eyelids in 19patients, more immediate reoperation was requiredforover-
correctionin5eyelidsandforundercorrectionin3eyelids. Sincetheneed
for reoperation is probably related to surgical technique, the question
arose: could animprovement in technique reduce the numberofreopera-
tions?
PROXIMALLEVATORTECHNIQUE
It occurred to me that division ofthe levator muscle in the superior orbit
proximaltoWhitnall'sligamentwouldcompletelydefunctionalizethemus-
cle, release all of its distal attachments, symmetrically lower the upper
eyelid, increasepostoperative eyelidadjustability, andreducethenumber
of reoperations. A single fixation suture in the proximal levator muscle
would support the upper eyelid and enable postoperative adjustment of
eyelid position. This reasoning underlies the proximal levator technique.
Withfewexceptions,33-36 surgeryofthe levatormuscle is performedon
its aponeurotic distal third in the eyelid. However, abnormalities in
Graves'eyediseaseprimarilyaffecttheproximaltwo-thirds ofthe muscle.
The technique tobe describedis theonlyeyelidrecession procedure per-
formed on the diseased proximal mu-scular portion of the levator in the
superior orbit.
732 Small
4, CUT EDGE OF LEVATOR
APONEUROSIS
/; - ADJUSTABLE SUTURE
FIGURE1
FromSmallRG:Controlled recessionoftheuppereyelid.Adv OphthalPlastReconstrSurg
1982; 1:267(Fig6).
ANATOMYOFTHEPROXIMALLEVATORMUSCLE
Because the proximal levator technique requires dissection ofthe levator
muscle in the superior orbit above the superior transverse ligament, ana-
tomicalconsiderationsarisethatdifferfromthosepertainingtothesurgery
ofthe distal aponeurotic portion ofthe muscle:
1. Is there danger of injuring the branches of the 3rd cranial nerve
supplyingthelevatormusclewhendissectioniscarriedoutabovethe
superior transverse ligament (STL)?
2. What is the anatomical and functional relationship ofthe proximal
levator muscle to the upper eyelid?
3. What is the function of Whitnall's ligament? Does it support the
upper eyelid?
Ananatomical studyoftheproximallevatormusclewasundertakeninan
attempt to answer these questions.
LevatorMuscle Surgery 733
DEFINITIONSANDTERMINOLOGY
The levatorpalpebrae superioris muscle (LPS) is muscular in the superior
orbitproximaltoWhitnall'sligament(proximal LPS). Distaltotheligament
in the eyelid, it is aponeurotic (levator aponeurosis or aponeurosis).
Whitnall's ligament is synonymous with superior transverse ligament
(STL).
METHODS
The author dissected eight orbits-four fresh orbits from autopsv speci-
mens and four orbits preserved for anatomical dissection-with special
emphasis on theproximal two-thirds ofthe muscle (proximal LPS)andthe
STL. Observations ofthe proximal LPS were made during surgery. The
findingsaresupplementedbyreferences totheworkofotherinvestigators.
FINDINGS
The LPS originates from the undersurface ofthe lesser wing ofthe sphe-
noid. The muscle measures 3 x 8 mm as it extends anteriorly over the
superiorrectusmuscleandwidensto12mmasitreachestheSTL1cmpos-
teriortotheseptumorbitaleand3mmanteriortothee(quatoroftheglobe.
Theproximalorbitaltwo-thirds ofthe LPS measures40mmfrom itsorigin
tothe STL. Distaltothe STLthelevatorchangesfrom ahorizontal muscu-
larband toan expandingaponeurotic curvedhoodwhichhugs theglobe of
theeyeandextendsverticallydownward. Thedistalone-thirdoftheLPSis
aponeurotic and is part of the upper eyelid. It begins at the STL and
extends 20mm to its insertion inthe lidcrease anddistal anteriortarsus.37
Medial and lateral extensions ofthe levator aponeurosis (horns)join with
the check ligaments of the superior rectus muscle and insert into the
medial and lateral orbital retinaculae. The total length of the muscle
measured to the distal anterior tarsus is 60 mm.
The3rdcranialnervebranchtothelevatorentersbeneath themiddleof
theproximal two-thirds ofthe muscle, 2cmfrom its origin and2cm proxi-
mal to the STL. The nerve gives offmultiple twigs as it extends distally.
Dissecting more than 2 cm above the STL could damage the nerve.
Relationship ofthe LPS Sheath
TheLPS liessuperiorandslightlymedialtothesuperiorrectusmuscle. Its
connective tissue sheath joins that ofthe superior rectus muscle below.
Distally the anteriorlevator muscle sheathblendswith the STL. The LPS
becomes aponeurotic distal to the STL. Aplane ofdissection between the
proximalLPSandsuperiorrectusmuscleisbeststartedmedially. Laterally
the proximal LPS fibers fan out in a curve and blend with the STL as it
734 Small
passes to its lateral orbital attachment. Careful dissection is necessary to
include all ofthese lateral fibers. Distal to the STL, levator muscle fibers
that extend into the aponeurosis are more prominent medially.38
The suspensory ligament of the fornix, an extension of the common
sheath ofthe levator and superior rectus muscles, supports the superior
conjunctival fornix39 (Fig 2A and B). The proximal LPS pulls on the
suspensory ligament of the fornix and the conjunctiva and elevates the
eyelidthroughitsconjunctivalattachmentaswellasthroughtheaponeuro-
sis. ThepulloftheprominentlateralproximalLPSfibersisalikelycausefor
the characteristic lateral elevation of the upper eyelid in Graves' eye
disease seen before and sometimes aftersurgery. Even complete transec-
tion of the levator aponeurosis and Muller's muscle does not eliminate
eyelid elevation caused by this conjunctival pull.
Whitnall's Ligament (STL)
Thefascial sheath ofthe levator muscle is continuous with the STLwhich
stretches transversely to reach the orbital walls on each side. The width,
configuration, and laxity ofthe STLvary. Mediallythe STLinserts on the
trochlea, the orbital wall, and the supraorbital notch; laterally it passes
through the lacrimal gland to the orbital wall and lateral retinaculum. A
pullonthelateral ligament meetsfirm resistance. Theattachmentis more
laxmedially. Theuppereyelidrotates upanddownonanaxisthroughthe
medial and lateral attachments of the STL like the visor ofa medieval
helmet. With levator contraction the STL moves back to apoint atwhich
LPS action is limited as noted by Whitnall.40
Supportofthe UpperEyelid
Althoughthe STLhasbeendescribedas supportingthe uppereyelid,41'42
recentanatomicalstudiessuggestthatthisisnotthecase.39Also, whenthe
proximal LPS is surgically transected in the proximal levator technique,
the eyelid closes without any support from the STL. It is the intact LPS,
Muller'smuscle, andtheglobeoftheeyethatsupporttheeyelid. Theglobe
must be present for the upper eyelid to be in normal position. The STL
doesnotpreventtheptosisassociatedwithanophthalmos andphthisisbul-
bi. When the anophthalmic patient without a prosthesis is asked to open
theeyes, thelevatorpullontheptoticeyelidisstraightback. Nordoesthe
STL act as a pulley. It plays a secondary role consistent with Whitnall's
originaldescriptionofitasacheckligamentthatlimitsthebackwardpullof
the LPS. It does not prevent the excessive levator action ofGraves' oph-
thalmopathy which Frueh has shown to range up to 25 mm.6