Contour Symmetry of the Upper Eyelid Following Bilateral Conjunctival-Müller’s Muscle Resection

Marcelo Golbert, MD; Filipe Jose Pereira, MD; Denny M. Garcia, PhD; and Antonio A.V. Cruz, MD


Background: Conjunctiva-Müller muscle resection (CMMR) is a simple, effective, and predictable procedure for internal treatment of ptosis.

Objectives: The authors determined contour symmetry of the upper eyelid following bilateral CMMR.

Methods: Thirty control participants (ie, without ptosis) and 44 patients with acquired bilateral blepharoptosis who underwent CMMR were evaluated in a prospective study. To assess symmetry of lid contour, distances from midpupil to the upper eyelid (ie, MPLDs) were determined radially at intervals of 15° (total, 180°) along the palpebral fissure, and MPLDs at each angle were compared for right and left eyes.

Results: For control participants, the mean marginal reflex distance (MRD1; ie, MPLD at 90°) ± standard error (SE) was 4.05 mm ± 0.75 mm, and small contour asymmetries (<10%) were measured for all angles. Medial (9.4% ± 4.7%) and lateral (8.1% ± 4.9 %) asymmetries were not significantly different for these participants. For patients with ptosis, the mean preoperative MRD1 was 2.56 ± 0.1 mm, and mean medial and lateral lid asymmetries (14.3% ± 8.4% and 16.7% ± 9.7%, respectively) were significantly higher than those of controls. Medial and lateral asymmetries correlated significantly with the extent of ptosis and were more pronounced laterally than medially. One month after CMMR, the lateral-medial discrepancy in lid asymmetry was resolved, and mean medial and lateral MPLDs (9.9% ± 7.5% and 8.5% ± 5.3%, respectively) were similar to those of controls.

Conclusions: For patients with involutional ptosis, CMMR enables elevation of the lid margin and correction of contour anomalies.

Level of Evidence: 2

Resection of conjunctiva and Müller’s muscle through a posterior approach (CMMR) has become popular among oculoplastic surgeons for treatment of mild involutional ptosis. There is consensus that CMMR is fast, simple, and predictable, whether the traditional closed technique or the open-sky variant is performed; the latter enables direct visualization of Müller’s muscle. Moreover, CMMR does not require intraoperative adjustments. Attaining symmetric eyelid contour is essential for satisfactory treatment of bilateral or unilateral ptosis. However, most proponents of CMMR regard changes in the marginal reflex distance (MRD1) as the only criterion of success. To test the assumption that CMMR consistently yields symmetric eyelid contour, we measured  pre- and postoperative distances from the midpupil to the upper lid (MPLDs) for patients with involutional ptosis who underwent bilateral CMMR.

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Filipe Pereira

Filipe Pereira

Secretário geral SBCPO - CRM-SC 7999

Mestrado e especialização em Plástica Ocular, Vias Lacrimais e Órbita pela Faculdade de Medicina de Ribeirão Preto – USP. Observational fellowship in ophthalmic plastic surgery – University of California of San Francisco. Diretor técnico da CCPO – Clínica Catarinense de Pálpebras e Olhos - Florianópolis. Secretário geral SBCPO