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Journal of Ophthalmic Surgery

Vol 5 | Issue 1 | Pages 71-74

ISSN: 2578-7160

Review Article

DOI: 10.36959/587/604

Minimally Invasive Transconjunctival Threading Methodof Shortening the Müller Muscle and the Levator
Aponeurosis in Severe Involutional Blepharoptosis
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Kosuke Ogasawara, MD, PhD* iD
Medical Corporation, Ogasawara Eye Clinic, Morioka Iwate, JapanAbstract
We have been performing involutional blepharoptosis repair by tucking the Müller muscle and levator aponeurosis withtransconjunctival threading for over 10 years, while striving to improve this technique. The aim of the present paper is tointroduce some progress in surgical quality.
The surgical technique described in this manuscript is performed in the following order: (1) The Müller muscle is exposed
after the conjunctival fornix incision and a 7-0 nylon thread with double armed needle (MANI3365) is passed throughthe tarsal side. (2) From this site, a thread is passed 5 mm through the underside of the tarsal plate, and then aftercoming out again on the tarsal plate side. (3) From this point re-thread again to the site of the conjunctival incision in theconjunctival fornix. (4) At this site, a double armed needle thread from above the Müller muscle to a sufficient depth,including the posterior layer of the levator aponeurosis, so that both arms intersect. This surgical process for enhancing
eyelid elevation is the most important in the present improved technique. (5) After ligation and checking the elevation ofeyelid is satisfactory, cut the suture and close the conjunctival incision site by coagulation.
This technique may be more useful for treating involutional blepharoptosis than the previously reported procedures if
the levator function is good. Additionally, we evaluated the safety, non-invasiveness, efficacy, and persistence of longterm surgical effects of this method and found that it can be recommended as a surgical procedure in severe cases as
marginal reflex distance-1 (MRD-1) of 1 mm or less. This method is also one that is recommended for elder adults who
use anticoagulants because the amount of blood during surgery is minimal.

Keywords
Involutional blepharoptosis, Internal approach, Müller muscle, Levator aponeurosis

Introduction
The number of patients with involutional blepharoptosis isincreasing due to the increase in the aged population, resulting
in a rise in the number of cases requiring surgery. There are twoconcepts of surgical methods for involutional blepharoptosis:
External and internal approaches (transconjunctival method)[1]. The surgical approach of the former is from the skin side,
while the latter is from the conjunctival side. The superiority
and inferiority of these methods have been discussed fromvarious perspectives [2,3]. Currently, the most commonlyused transconjunctival ptosis surgery is shortening of Müller’smuscle (Müller muscle conjunctival resection), which is also
used for severe cases [3] in Western countries; however,
the greater degree of intraoperative and postoperative
invasiveness is an issue.
Selection of the surgical method is determined by thesurgeon according to each patient’s situation. The mostimportant point for this selection is safety and efficacy.

Given the importance of minimally invasive surgery for theincreasingly elderly patient cohort, we pursued the feasibilityof ptosis surgery with transconjunctival threading andfound that this procedure was useful [4]. Subsequently, thisprocedure has been improved to expand the scope of surgery
indications, and we have reported the better results [5].
However, some severe cases (MRD-1 of 1 mm or less) have*Corresponding author: Kosuke Ogasawara, MD, PhD, MedicalCorporation, Ogasawara Eye Clinic, 3-10-12, Takamatsu,
Morioka Iwate 020-0114, Japan, Tel: +81-19-(662)-3223, Fax:+81-19-(662)-7331
Accepted: January 29, 2022
Published online: January 31, 2022
Citation: Ogasawara K (2022) Minimally Invasive Transconjunctival Threading Method of Shortening the Müller Muscle andthe Levator Aponeurosis in Severe Involutional Blepharoptosis.
J Ophthalmic Surg 5(1):71-74

Copyright: © 2022 Ogasawara K. This is an open-access article distributed under the terms of
the Creative Commons Attribution License, which permits unrestricted use, distribution, andreproduction in any medium, provided the original author and source are credited.

ScholarlyPages
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D IRECT

Open Access | Page 71 |

Citation: Ogasawara K (2022) Minimally Invasive Transconjunctival Threading Method of Shortening the Müller Muscle and the Levator
Aponeurosis in Severe Involutional Blepharoptosis. J Ophthalmic Surg 5(1):71-74

Figure 1: How the final state of the Müller muscle and posterior layer of the levator aponeurosis should look when a double armed
needle threading from the Müller muscle to the posterior layer of the levator aponeurosis.

experienced insufficient persistence of eyelid elevation after
surgery and recurrence, which is a point for improvement.
Here, we present a modified threading method of theMüller muscle and levator aponeurosis, which is a noninvasive procedure. Furthermore, we describe the surgicalresults of this method obtained thus far for perspectives.

Subjects
This review article included adults with blepharoptosis.
Written informed consent was obtained from all the subjects.
This study was conducted as per the tenets of the Declarationof Helsinki. Patients whose image appears in this publication
provided additional written consent for publication.
Preoperative and postoperative MRD-1 was measured using
anterior segment OCT (CASIA2, Tomey Corporation, Nagoya,Japan) [6] to ensure accuracy, and Bonferroni’s method wasused for the statistical significance test.
From 60 patients with involutional ptosis, 91 eyes
underwent surgery in the past three years using the method
reported here. Of these, severe patients (MRD-1 < 1 mm)
who were followed for more than one year (follow-up was
conducted every three months after surgery) consisted 3
males and 16 females (25 eyes in total), with a mean age of
68.9 years were focused. Preoperative levator function was
better in all patients with 8 mm or higher and an average of
10.68 mm. The results of phenylephrine testing were positivefor 11 patients and negative for 8 patients.

Surgical Procedures
1) After anesthetizing with anesthetic eye drops, invert theupper eyelid and perform local anesthesia below the tarsal
plate using 1% lidocaine without sympathomimetics. 2) Grasp
the tarsal plate at 5 mm away from the eyelid using the tips ofthe fixation forceps (INAMI® S361) and invert the tarsal plate.
3) Apply a small amount of local anesthesia at approximately
5 mm away from where the forceps are holding the tarsal
plate and make an incision approximately 5 mm wide into theOgasawara. J Ophthalmic Surg 2022, 5(1):71-74conjunctiva using a high frequency scalpel, taking care not todamage the Müller muscle. 4) Thread 7-0 nylon double armed
thread (MANI®3365) approximately 3 mm from the eyelid
margin into the tarsal plate under the Müller muscle. 5) Thread
approximately a further 5 mm through to the underside of thetarsal plate, and then, after coming out again on the tarsal plateside, re-thread again to the site of the conjunctival incision of
the conjunctival fornix. 6) At this site, thread a double armed
suture from above the Müller muscle to a sufficient depth,including posterior layer of the levator aponeurosis, so thatboth arms intersect. 7) After checking that the elevation of
the eyelid is satisfactory, coagulate the conjunctival incisionsite and close. The above procedures are presented in thesupplementary video and an image of the sagittal section of
the upper eyelid after surgery is shown (Figure 1).
When compared with the previous paper [5],improvements in this surgical method include the following
aspects: First, the Müller muscle was exposed after incising
the conjunctiva. From this area, a thread was passed throughthe tarsal side and re-thread again to incised conjunctival
fornix. Then, the thread was passed through the posterior
layer of the levator aponeurosis and ligated for enhancing
eyelid elevation (Figure 2). This process is the most importantin the present improved technique, which is based on theproved anatomical findings [7]. Additionally, the tucking
width of the Müller muscle and levator aponeurosis could bechanged (by approx. 6 mm) by adjusting the threading siteaccording to the distance from the tarsus, controlling thedegree of eyelid elevation.

Results
In severe involutional blepharoptosis, changes in MRD1 improvement at 3 months, 6 months, and one year aftersurgery in 25 eyes are shown in Figure 3. The figure shows that
there is no significant decrease in postoperative MRD-1 ofeach examined period for one year after surgery, which means
sufficient persistence of eyelid elevation. These patients
Open Access | Page 72 |

Citation: Ogasawara K (2022) Minimally Invasive Transconjunctival Threading Method of Shortening the Müller Muscle and the Levator
Aponeurosis in Severe Involutional Blepharoptosis. J Ophthalmic Surg 5(1):71-74

AB

Figure 2: A) How the sagittal section should look after making the ligature of the Müller muscle and the levator aponeurosis.
B) Over the view of the ligature.

Figure 3: Pre-operative MRD-1 values and changes in MRD-1 improvement at 3 months, 6 months and one year after surgery in 25
eyes of severe involutional blepharoptosis. Post-operative MRD-1 is significantly improved than pre-operation (p < 0.01). There is nosignificant decrease in post-operative MRD-1 of each examined period after surgery (Bonferroni’s method).

underwent ptosis correction only, and no blepharoplasty was
performed for eyelids skin laxity. Furthermore, intraoperative
bleeding among five patients who used anticoagulants
was minimal. Postoperatively, several patients had slightcorneal erosion, eyelid swelling, and subcutaneous eyelid
bleeding, however, those are disappeared within a week with
ophthalmic solutions. There were no cases of postoperative
overcorrection or severe complications.

Conclusion
We have confirmed that as long as the levator function
is good, the present technique is useful for the patientswith severe involutional blepharoptosis (MRD-1 < 1 mm).
This procedure, through threading and fixing not only theMüller muscle, but also the posterior layer of the levator
aponeurosis, appears to increase and stabilize the elevation
strength of the eyelids. Moreover, surgery time is short withalmost no bleeding. The post-operative burden on patients inOgasawara. J Ophthalmic Surg 2022, 5(1):71-74

terms of eyelid swelling and pain etc. is also reduced, meaningthat this procedure can be performed safely even on elderly
patients and those taking anticoagulants.
There also appears to be advantage for double eyelids
and in terms of there being minimal impact on the shape ofthe eyelid, less postoperative overcorrection, the ability to
re-operate, and that it is easy to perform if simultaneously
performing surgery to treat blepharochalasis.
Cases for which this surgery would not be suitable include
patients with congenital ptosis, patients with acquired ptosis
following a neurological disorder or ophthalmic surgery andpatients with poor levator function. Ptosis seen in patients
who have side effects of glaucoma medication over a long
period such as DEUS (deepening of upper eyelid sulcus) and/or PAP(prostaglandin-associated periorbitopathy) maybe
treated by another procedures.
Open Access | Page 73 |

Citation: Ogasawara K (2022) Minimally Invasive Transconjunctival Threading Method of Shortening the Müller Muscle and the Levator
Aponeurosis in Severe Involutional Blepharoptosis. J Ophthalmic Surg 5(1):71-74

Disclosure
The author reports no conflict of interest.

Acknowledgement
The author would like to thank Mr. Hisato Nakatsubo for
editing the surgical video and Mr. William Faris for his English
narration of the video.

References
1. Allen RC, Saylor MA, Nerad JA (2011) The current state of ptosis
repair: A comparison of internal and external approaches. Curr
Opin Ophthalmol 22: 394-399.
2. Saonanon P, Sithanon S (2018) External Levator Advancement versus Muller Muscle-Conjunctival Resection for Aponeurotic Blepharoptosis: A Randomized Clinical Trial. Plast Reconstr
Surg 141: 213e-219e.

3. Sweeney AR, Dermarkarian CR, Williams KJ, et al. (2020)
Outcomes after Müller Muscle Conjunctival ResectionVersus External Levator Advancement in Severe Involutional
Blepharoptosis. Am J Ophthalmol 217: 182-188.
4. Odashima S, Ogasawara K (2006) New suture technique tocorrect ptosis without incision of the eyelid or the conjunctiva.
Jap J Ophthalmic Surg 19: 579-582.
5. Ogasawara K (2019) Ptosis surgery with an improved method ofshortening the Müller muscle and the levator aponeurosis withtransconjunctival threading. J Ophthalmic Surg 2: 7-12.
6. Ogasawara K (2020) Application of Second-Generation SweptSource Anterior Segment-OCT in the Measurement of Marginal
Reflex Distance-1 (MRD-1). Clin Ophthalmol 14: 635-642.
7. Kakizaki H, Zako M, Nakano T, et al. (2005) The levator
aponeurosis consists of two layers that include smooth muscle.
Ophthalmic Plast Reconstr Surg 21: 379-382.

DOI: 10.36959/587/604
Copyright: © 2022 Ogasawara K. This is an open-access article distributed under the terms of
the Creative Commons Attribution License, which permits unrestricted use, distribution, andreproduction in any medium, provided the original author and source are credited.

S CHOLARS. D IRECTOgasawara. J Ophthalmic Surg 2022, 5(1):71-74

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