The Ophthalmology Department,  Universiti Malaysia Sarawak (UNIMAS), Kuching, Sarawak.

The Ophthalmology Department, Sarawak General Hospital, Kuching, Sarawak, East Malaysia.

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Case 34

by Dr. Mahadhir Alhady & Professor Chua Chung Nen

 

Congenital ptosis with poor levator function is the most common type of ptosis seen in young children. The surgical method of choice is to perform frontalis suspension using either synthetic materials (for example prolene and mersilene mesh) or autologous tissues (such as fascia lata and palmaris longus1). And the most commonly used instrument to introduce these materials is the Wright needle. However, we find the Wright needle requires the use of a bigger skin wound and causes more trauma. The instrument that we commonly employ in our department is the 18-gauge intravenous catheter2. It has several advantages:

  • smaller size means better cosmetic result and less trauma,

  • it is cheap and disposable,

  • the tip is always sharp because it is not re-used.

Figure 1. Showing the difference in size between a Wright needle and a G18 gauge

catheter needle.

 

Figure 2. A big wound and more tissue manipulation with a Wright needle (right) than

with a G18 needle.

 

Surgical techniques

  • A Fox3 pentagon was used with five stab incisions using no. 11 blade, two in the eyelid, two in the superior eyebrow margin, and one in the forehead.

  • The 18-gauge intravenous catheter needle was inserted through the incision sites.

  • A lid guard was placed between the globe and the eyelid to avoid accidental penetration of the eye by the needle.

  • The 2/0 prolene was introduced through the needle lumen to be placed deep to the orbicularis and
    frontalis muscles (Figures below).

  • The sutures were lifted and tied at the forehead incision to achieve the satisfactory lid height and contour. Only the forehead incision needs suturing with 6.0 Vicryl to prevent protrusion of the suture ends.

We have used this technique in 15 patients (22 eyelids) with good cosmetic results.

 

Figure 3. Refer to surgical techniques for explanation. Only the upper most forehead scar

needs suturing (K and L). 

 

a. What is the disadvantage of this technique?

 

 

b. What alternative instrument may be used?