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Levator Aponeurosis Surgery
OCTOBER 1991, VOL 54, NO 4
AORN JOURNAL
Levator Aponeurosis Surgery SURGICAL CORRECTION FOR BLEPHAROPTOSIS Florita G . Langseth, RN lepharoptosis is a condition in which the upper eyelid position is abnormally low. The term is from the Greek words btepharon, meaning eyelid, and ptosis, meaning fall. Blepharoptosis is more commonly known by the shorter term ptosis. The eyelid’s position is measured from the superior limbus (ie, junction where cornea and sclera meet) with the patient looking straight ahead or in the primary position (Fig 1). Ptosis may be transmitted as a dominant trait and be present at birth, but it more commonly develops later in life from a variety of causes. Several conditions simulate ptosis. Enophthalmos (ie, recession of the eye into the orbit) and hypertropia (ie, deviation of one eye upward) can mimic ptosis. These conditions should be differentiated from true ptosis to determine the most suitable corrective surgical procedure.
slightly with the eye closed and is below the cornea with the eye open. The skin on the eyelids easily wrinkles and forms folds. Less than a millimeter thick, the skin is loose and elastic and is the thinnest on the body. The pull of the levator palpebrae superioris muscle tendon produces the crease in the upper lid that can be seen when the eye is open. The tarsal plates of the lids, made of dense fibrous connective and some elastic tis-
Upper Eyelid Anatomy
T
he eyelids are mobile skin folds that act as curtains protecting the eye from injury and excessive light. The eyelids also help the pupil regulate the amount of light entering the retina. The upper eyelid, which is more mobile than the lower, is served by a special elevator muscle called the levator palpebrae superioris (Fig 2). When the eye is open and looking straight ahead, the upper eyelid just covers the superior portion of the cornea, and it covers the whole cornea when the eye is closed. The lower lid, however, rises only
Florita (Cotie) G. Langseth, RN, BSN, CRNO, is a clinical RN level 111 at The Methodist Hospital, Houston. She earned her bachelor of science degree in nursing from the University of Santo Tomas, Manila, Philippines. The author acknowledges the assistance of James R. Patrinely, MD, assistant professor of ophthalmology and plastic surgery, Baylor College of Medicine, Houston, and wishes to thank Alex Kirin, CRNA, The Methodist Hospital, Houston, for his help. 731
OCTOBER 1991, VOL 54, NO 4
AORN JOURNAL
pupil
I
iris
cornea
canthus
sues, form the skeleton of the lids and give them shape, support, and firmness. The levator palpebrae muscle is innervated by the third cranial nerve (ie, oculomotor nerve). Its aponeurosis (from the Greek apo [from] and neuron [nerve or tendon]) is a flat, fibrous sheet of connective tissue that attaches the levator muscle to the anterior portion of the tarsal plate and elevates the upper lid. This aponeurosis (ie, tendon of the levator muscle)
Fig 1. External landmarks of the eye. can weaken or become detached, causing acquired ptosis (Fig 3).
Degree of Ptosis
T
he amount of ptosis is measured in millimeters comparing both eyes when the patient is looking straight ahead. The relative eyelid positions to the cornea and pupil also are measured. The distance from the upper
levator orbicularis oculi muscle gland of Wolfring
levator pabebrae aponeurosis superior tarsal muscle
er eyelid retractors
.-.
Fig 2. Cross section of the upper lid. (Reprinted from “Anatomy and embryology of rhe eve, K F Tabbara, General Ophthalmology (19891,D Vaughn, 1’Asbury, K F Tabbara, eds, wirh permission from Appletori & Lange, Norwalk, Conn) ”
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OCTOBER I99 1, VOL 54, NO 4
eyelid margin to the superior limbus is measured as well. The upper eyelid is considered normal at 1 mm below the superior limbus. Measurement of 2 mm below the limbus is considered mild ptosis, 3 mm is moderate, and 4 mm or more below the superior limbus is considered severe ptosis.'
Classification of Ptosis
T
here are several types of ptosis and various forms of classification, but the simplest system classifies ptosis as congenital or acquired. Congenital. Congenital ptosis usually results from poor development of the levator muscle, either alone or in conjunction with superior rectus muscle anomalies. It is important to identify problems that may coexist with congenital ptosis. Assessment of ocular function to rule out amblyopia (ie, uncorrected blurred vision in one eye due to disuse of the eye), anisometropia (ie, difference in refractive error of the eyes-one eye is farsighted, other eye is nearsighted), astigmatism fie, refractive error that prevents light rays from coming to a single focus on the retina because of corneal irregularity), and strabismus (ie, deviation of one or both eyes from the proper direction) is essential. These conditions may need to be corrected before ptosis correction is undertaken. Acquired. The etiology of acquired ptosis may include several factors classified as neurogenic-factors that affect the oculomotor nerve supplying the muscle (ie, paralysis, stroke, nerve injury), myogenic-factors associated with diseases like myasthenia gravis and muscular dystrophy, traumaticdamage to the levator muscle or aponeurosis in acute facial trauma, and mechanical-any increase in weight of the eyelid from tumors, scar tissue, extra fatty tissue, andor acute or chronic edema and inflammation. In addition, patients on chronic corticosteroid therapy can have corticosteroid-induced ptosis which is presumed to be of myogenic
AORNJOURNAL
origin, perhaps a localized form of corticosteroid myopathy.*
Preoperative Evaluation
I
mproved vision and appearance are the main reasons to correct ptosis. Most insurance companies require detailed and complete documentation including preoperative photographs. Photographs of the patient before and after surgery are a standard part of this do~umentation.~ Careful and thorough preoperative evaluation of each individual patient is required to
Fig 3. A patient with acquired ptosis as shown preoperatively. properly correct ptosis. Factors to be addressed include4 the presence or absence of familial ptosis, age of onset, history of trauma, medications used by patient (topical and systemic), whether ptosis worsens with fatigue, and whether there are systemic illnesses that might be related to the ptosis. The first questions are asked to determine if the ptosis is congenital or acquired. This often can be determined by reviewing old photographs of the patient to determine if he or she has had ptosis from childhood or if it was recently acquired. General eye examinations, including measurement of visual acuity, ocular rotations, retinoscopy, and a dilated fundus examination, are conducted. The Schirmer test, a diagnostic test for dry eyes, also is performed to deter-
d+ 733
AORN JOURNAL
mine lacrimal function and adequacy of tear film. This test is conducted by placing a strip of filter paper in the conjunctival sac of the lower eyelid. This stimulates lacrimal gland secretions, The paper is left in place for five minutes with the patient’s eyes closed. The wet area on the paper is then measured. A wet area of 15 mm or more is considered normal, and a measurement of less than 15 mm is considered decreased tear production. Adequate tear function is imperative because the eyelid may not close completely after the ptosis correction. This could lead to dry eyes if tear function is not adequate. Therefore, if the ptosis does not impair visual acuity and there is no marked cosmetic deformity, the condition is best left alone. A key element in the preoperative evaluation is determining the amount of levator function. The surgical correction depends largely on the functional strength of the levator muscle. Levator function is determined by placing a ruler at the temporal side and asking the patient to look straight ahead, then all the way down. The zero point is noted at the edge of the closed upper lid. The patient then looks all the way up, and the position of the lid is noted on the ruler. The measurement may be up to 20 mm, and less than 10 mm is considered decreased levator function.
Preoperative Cure
P
atients exhibit many emotions and reactions upon learning that they must undergo a surgical procedure. Their principal concern is the success of the operation. The age of patients undergoing eye surgery varies, and each age group has specific needs. With outpatient surgery on the increase, the operating room staff members must not only meet each individual’s needs and provide care but also prepare the patient and family or friends for home care. Proper communication with the physician’s office is necessary to aid in coordination of care and teaching, which increase the efficiency and effectiveness of care. Levator aponeurosis repair is performed on 736
OCTOBER 1991, VOL 54, NO 4
an outpatient basis. The anesthesiologist and the admission observation and discharge (AOD) nurse conduct a preoperative visit the day before surgery or early the morning of surgery. The preoperative evaluation session helps educate patients and their family members. Explaining routine admission procedures helps relieve anxiety. The AOD nurse obtains pertinent medical information and witnesses the patient’s or parent’s signature on the informed consent form if it was not signed at the physician’s office. The anesthesiologist discusses the types of anesthesia, anesthetics and sedatives, and all necessary monitoring equipment. For adults, local infiltration anesthesia with monitored anesthesia care is the anesthesia of choice because patient cooperation is needed during the procedure. Preoperative medical assessment is important because it provides the anesthesiologist with a plan of preoperative management, an evaluation of risks, and a baseline determination of the patient’s condition. The patient’s family members and/or friends should be included in the teaching because their presence may help the patient better understand the planned procedure; they also provide support. The AOD nurse reviews and reinforces all verbal and written information and answers any questions. He or she reminds the patient not to eat or drink after midnight, unless his or her physician allows certain medications by mouth with a sip of water on the morning of surgery. The nurse reminds women not to wear makeup the day of surgery. Unless indicated by age or medical condition, no laboratory tests are ordered. On the day of surgery, the patient arrives at the AOD unit where the AOD nurse introduces himself or herself to the patient and family members. Family members of an adult patient go to the waiting area while parents of an infant or child stay with the patient until the circulating nurse is ready to take the patient into the operating room. The AOD nurse instructs the patient to remove all clothing and gives him or her a gown, hair covering, and booties to wear. The patient gives all valuables to a family
OCTOBER 1991, VOL 54, NO 4
AORN JOURNAL
Fig 4. Lid crease marked with incision line and skin retracted showing preaponeurotic fat pad. (Reprinted from “Evaluationand management of the ptosis patient, R Waller, C D McCord, M Tunenbaum, Oculoplastic Surgery, second ed (1987),C D McCord, M Tanenbaum, eds, with permission from Raven Press, New York City)
Fig 5. Sutures placed on nasal, central, and temporal edges of aponeurosis. Sutures attached to anterior-superiortarsus. (Reprintedfrom “Evaluationand management of the ptosis patient, R Waller, C D McCord, M Tanenbaum, Oculoplastic Surgery, second ed (1987), C D McCord, M Tunenbaum, eds, with permissionfrom Raven Press, New York City)
member or puts them in the hospital safe at the admitting office. The nurse then assists the patient onto a stretcher and puts a warm blanket on him or her for comfort. An anesthesiologist or nurse anesthetist starts an IV line providing lactated Ringer’s solution. The circulating nurse and the scrub nurse prepare the operating room according to the surgical procedure planned and the surgeon’s preferences. When the room is ready, the circulating nurse greets the patient in the AOD unit and introduces himself or herself and other members of the surgical team. He or she makes another preoperative assessment based on the preoperative evaluation documented by the AOD nurse. The circulating nurse explains
operating room routine, answers any questions, and ensures that the patient is comfortable and understands the procedure. While still in the AOD unit, the surgeon marks the patient’s lid creases and any excess skin with toothless forceps and a marking pen. The drawing identifies the incision lines before the tissues are distorted by local anesthetics. Children’s lids usually are marked after they are asleep. The nurse informs the patient that he or she may be asked to move to a semi-sitting position during the procedure. The patient may be asked to look straight ahead, up, or down to fully elevate the eyelids. This is necessary for the surgeon to make adjustments to the eyelid contour
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OCTOBER 1991, VOL 54, NO 4
AORN JOURNAL
and height. Long, split drapes maintain sterility as the patient sits up.
Intraoperative Care
T
he circulating nurse and the anesthesiologist or nurse anesthetist bring the patient to the operating room and assist in the safe transfer of the patient to the OR bed. The patient is placed supine in a slight reverse Trendelenburg position. The nurse secures the safety strap across the patient’s thighs and pads elbows and heels. He or she attaches monitoring equipment for vital signs, electrocardiogram, and oxygen saturation. The patient’s arm closest to anesthesia is placed on Fig 6. Sutures are tied permanently and skin incision closed. an armboard; the opposite arm is Cross-section view shows suture placement. (Reprinted from loosely restrained at the wrist “Evaluation and management of the ptosispatient, R Walter, C and tucked securely by the D McCord, M Tanenbaum, Oculoplastic Surgery, seconded patient’s side. The nurse also (1987), C D McCord, M Tanenbaum, eds, with permission from ensures that the patient is warm Raven Press, New York City) and comfortable and provides emotional reassurance as needmizes tissue distortion caused by the injected ed. The circulating nurse prepares a mixture of drug. The epinephrine in the lidocaine prolongs the local anesthetic that the surgeon injects the analgesia, decreases the rate of systemic before skin preparation. The local injection is a absorption, and enhances hemostasis. Because mixture of % mL of 1% lidocaine hydrochlopatient safety and comfort are priorities, the ride with 1:100,000 epinephrine and 4% mL of smallest amount of local anesthetic that has the bacteriostatic sodium chloride. It is injected desired effect is used. Proparacaine and tetrawith a 5-mL syringe and a 30-gauge, %-inch caine hydrochloride 0.5% ophthalmic solutions needle. This diluted anesthetic numbs the skin (topical anesthetics) are instilled into the eye. without burning and allows a painless injection The circulating nurse prepares the patient’s of the full strength anesthetic that follows. skin by washing the entire face and upper neck, The next injection contains a half-and-half including the oxygen nasal cannula. The prep mixture of 2% lidocaine hydrochloride with solution is povidone-iodine and is washed off 1:100,000 epinephrine and hyaluronidase and completely with sterile saline. The nurse 0.75% bupivacaine hydrochloride in a 12-mL explains the skin prep as he or she proceeds and syringe with a 30-gauge, %-inch needle. One to reminds the patient to keep his or her eyes 2 mL is injected into the eyelid to be corrected. closed to prevent any prep solution from enterMore may be given during the procedure if the ing the eyes. patient experiences any discomfort. The The scrub nurse and the surgeon drape the hyaluronidase increases dispersion and mini”
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OCTOBER 1991,VOL54,NO4
The surgeon places the patient with a head drape, a suture bites in the anteriortowel across the chest, and a superior tarsus and through large split sheet with the the aponeurosis, initially edges going around the using temporary or slip patient’s head. The circulatknots. The patient is asked to ing nurse also gives the scrub nurse local anesthetic for the look up or down and may be assisted to a sitting position back table in case additional by the circulating nurse and local infiltration is needed the anesthesia personnel. during the procedure. The surgeon places a sponge Fig 7. The surgeon places suture at Restraints andlor straps are soaked in cool saline over the the central edge of the aponeurosis. temporarily loosened to allow the patient to sit up unoperative eye to shade it comfortably while adjustf roin the bright over h e ad ments are made. In cases that require general lights. anesthesia (eg, congenital cases in children), The drooping eyelid is elevated by repairing, the aponeurotic tendon is advanced approxishortening. or advancing the levator aponeurotmately 3 to 4 mm for each millimeter of ptosis ic tendon. With a #1S blade, the surgeon makes present preoperative1y .5 an incision at the previously marked lid crease and follows with careful dissection to minimize When the eyelid is at the desired height, the sutures are tied permanently (Fig 6). The tentissue trauma. don is not cut or resected. One end of the tenA bipolar cautery is used for hemostasis because it can be used in a dry or wet area and don is attached to the anterior-superior portion of the tarsus. The skin edges are sometimes causes minimal patient discomfort and tissue sutured to the aponeurosis (with a skin-aponeudamage. The surgeon gently retracts the skin rosis-skin bite) to create a better lid crease. The with small. double-pronged skin hooks and surgeon closes the remainder of the skin with trims the preaponeurotic fat pads as necessary (Fig 4). The surgeon asks the patient to look up interrupted or running suture (Fig 7). or down so he or she can find the aponeurosisThe only dressings required are topical opha mobile. white, glistening tendon. The surgeon thalmic ointments. One ointment is a combinaplaces 6-0 nylon suture at the nasal. central, and tion steroid/antibiotic for the wound, and another is a lubricant for the eye. The nurse applies temporal edges of the aponeurosis and either eyepads soaked in iced saline over the eyelids. reattaches or advances the tendon (Fig 5).
Fig 8. A patient with acquired ptosis before surgical correction (left) and the same patient shown one week postoperatively (right). 740
OCTOBER 1991. VOL 54, NO 4
He or she gives the remaining bottle of iced saline to the patient for home ice compresses.
Postoperative Care
A
fter the procedure, the circulating nurse and the anesthesia personnel take the patient back to the AOD unit for observation. Both give a report to the AOD nurse. In cases where general anesthesia is used (usually children), patients are taken to the postanesthesia care unit before they are taken back to the AOD unit. The nurse in the recovery area applies ice compresses over the eyelids to control bleeding and swelling, which is minimal. The head of the bed is kept elevated for the same reason. When the patient is stabilized, the nurse reviews and reinforces postoperative instructions. Diet. The patient can resume eating gradually except for hot liquids, which are contraindicated for at least 24 hours to prevent vasodilation and bleeding. Activities. The patient can resume normal activity gradually but should avoid strenuous activities (eg, bending, heavy lifting). Showering is allowed. The nurse advises the patient to sleep with an extra pillow under his or her head. Medication. All previous medications are resumed and the surgeon orders a prescription for pain and discomfort (usually hydrocodone/ acetaminophen). Aspirin should be avoided. The patient lubricates the eye at bedtime with a topical ointment (eg, ocular lubricant, neomycinpolymycin-dexamethasone ointment). Ice compresses. The patient is advised to apply ice compresses every hour while awake for 15 to 20 minutes for the first 48 hours. Follow-up visit. The patient makes an appointment to return to the physician’s office the next day. Patients also are instructed to call if they experience severe pain in or behind the eye or notice a marked change in vision. The surgeon usually calls the patient at home the night after surgery to ask if he or she has any problems or questions. When the patient is stable as assessed by the
AORN JOURNAL
anesthesiologist, the AOD nurse proceeds with discharge procedures. Figure 8 shows a patient with acquired ptosis before and after surgical correction.
Conclusion
T
o properly manage ptosis, the etiology must be assessed. In recent years, more thorough understanding and knowledge of the anatomy and physiology of the eyelid have led to more conservative approaches to correct the pathophysiology. Needless sacrifice of healthy eyelid tissue, which may interfere with tear function, can be avoided. As with any other type of surgical procedure, there are risks and complications involved in levator aponeurosis repair. The most common and easily corrected complications are overcorrection and undercorrection, which occur only occasionally in experienced hands. Another possible complication is lid asymmetry, which can result from sutures that are too tight. Other rare and some relatively minor complications reported are postoperative hemorrhage, lid infections, keloid formation, and mild suture granuloma. The success rate is determined by what one is willing to accept as a good result.6 r: Notes 1. R Waller, C D McCord, M Tanenbaum, “Evaluation and management of the ptosis patient,” Oculoplastic Surgery, second ed, C D McCord, M Tanenbaum, eds (New York City: Raven Press, 1987) 333. 2. Ibid, 330. 3. Ibid, 334. 4. Ibid,332. 5. A J Berlin, K P Vestal, “Levator aponeurosis surgery: A retrospective review,” Ophthalmology 96 (July 1989) 1033-1036. 6. Ibid, 1035. Suggested reading Boyd-Monk, H; Steinmetz 111, C G. Nursing Care of the Eye. Norwalk, Conn: Appleton & Lange, 1987. Vaughan, D; Asbury, T; Tabbara, K F, eds. General Ophthalmology, twelfth ed. Norwalk, Conn: Appleton & Lange, 1989. 741
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Levator Aponeurosis Surgery SURGICAL CORRECTION FOR BLEPHAROPTOSIS Florita G . Langseth, RN lepharoptosis is a condition in which the upper eyelid position is abnormally low. The term is from the Greek words btepharon, meaning eyelid, and ptosis, meaning fall. Blepharoptosis is more commonly known by the shorter term ptosis. The eyelid’s position is measured from the superior limbus (ie, junction where cornea and sclera meet) with the patient looking straight ahead or in the primary position (Fig 1). Ptosis may be transmitted as a dominant trait and be present at birth, but it more commonly develops later in life from a variety of causes. Several conditions simulate ptosis. Enophthalmos (ie, recession of the eye into the orbit) and hypertropia (ie, deviation of one eye upward) can mimic ptosis. These conditions should be differentiated from true ptosis to determine the most suitable corrective surgical procedure.
slightly with the eye closed and is below the cornea with the eye open. The skin on the eyelids easily wrinkles and forms folds. Less than a millimeter thick, the skin is loose and elastic and is the thinnest on the body. The pull of the levator palpebrae superioris muscle tendon produces the crease in the upper lid that can be seen when the eye is open. The tarsal plates of the lids, made of dense fibrous connective and some elastic tis-
Upper Eyelid Anatomy
T
he eyelids are mobile skin folds that act as curtains protecting the eye from injury and excessive light. The eyelids also help the pupil regulate the amount of light entering the retina. The upper eyelid, which is more mobile than the lower, is served by a special elevator muscle called the levator palpebrae superioris (Fig 2). When the eye is open and looking straight ahead, the upper eyelid just covers the superior portion of the cornea, and it covers the whole cornea when the eye is closed. The lower lid, however, rises only
Florita (Cotie) G. Langseth, RN, BSN, CRNO, is a clinical RN level 111 at The Methodist Hospital, Houston. She earned her bachelor of science degree in nursing from the University of Santo Tomas, Manila, Philippines. The author acknowledges the assistance of James R. Patrinely, MD, assistant professor of ophthalmology and plastic surgery, Baylor College of Medicine, Houston, and wishes to thank Alex Kirin, CRNA, The Methodist Hospital, Houston, for his help. 731
OCTOBER 1991, VOL 54, NO 4
AORN JOURNAL
pupil
I
iris
cornea
canthus
sues, form the skeleton of the lids and give them shape, support, and firmness. The levator palpebrae muscle is innervated by the third cranial nerve (ie, oculomotor nerve). Its aponeurosis (from the Greek apo [from] and neuron [nerve or tendon]) is a flat, fibrous sheet of connective tissue that attaches the levator muscle to the anterior portion of the tarsal plate and elevates the upper lid. This aponeurosis (ie, tendon of the levator muscle)
Fig 1. External landmarks of the eye. can weaken or become detached, causing acquired ptosis (Fig 3).
Degree of Ptosis
T
he amount of ptosis is measured in millimeters comparing both eyes when the patient is looking straight ahead. The relative eyelid positions to the cornea and pupil also are measured. The distance from the upper
levator orbicularis oculi muscle gland of Wolfring
levator pabebrae aponeurosis superior tarsal muscle
er eyelid retractors
.-.
Fig 2. Cross section of the upper lid. (Reprinted from “Anatomy and embryology of rhe eve, K F Tabbara, General Ophthalmology (19891,D Vaughn, 1’Asbury, K F Tabbara, eds, wirh permission from Appletori & Lange, Norwalk, Conn) ”
732
OCTOBER I99 1, VOL 54, NO 4
eyelid margin to the superior limbus is measured as well. The upper eyelid is considered normal at 1 mm below the superior limbus. Measurement of 2 mm below the limbus is considered mild ptosis, 3 mm is moderate, and 4 mm or more below the superior limbus is considered severe ptosis.'
Classification of Ptosis
T
here are several types of ptosis and various forms of classification, but the simplest system classifies ptosis as congenital or acquired. Congenital. Congenital ptosis usually results from poor development of the levator muscle, either alone or in conjunction with superior rectus muscle anomalies. It is important to identify problems that may coexist with congenital ptosis. Assessment of ocular function to rule out amblyopia (ie, uncorrected blurred vision in one eye due to disuse of the eye), anisometropia (ie, difference in refractive error of the eyes-one eye is farsighted, other eye is nearsighted), astigmatism fie, refractive error that prevents light rays from coming to a single focus on the retina because of corneal irregularity), and strabismus (ie, deviation of one or both eyes from the proper direction) is essential. These conditions may need to be corrected before ptosis correction is undertaken. Acquired. The etiology of acquired ptosis may include several factors classified as neurogenic-factors that affect the oculomotor nerve supplying the muscle (ie, paralysis, stroke, nerve injury), myogenic-factors associated with diseases like myasthenia gravis and muscular dystrophy, traumaticdamage to the levator muscle or aponeurosis in acute facial trauma, and mechanical-any increase in weight of the eyelid from tumors, scar tissue, extra fatty tissue, andor acute or chronic edema and inflammation. In addition, patients on chronic corticosteroid therapy can have corticosteroid-induced ptosis which is presumed to be of myogenic
AORNJOURNAL
origin, perhaps a localized form of corticosteroid myopathy.*
Preoperative Evaluation
I
mproved vision and appearance are the main reasons to correct ptosis. Most insurance companies require detailed and complete documentation including preoperative photographs. Photographs of the patient before and after surgery are a standard part of this do~umentation.~ Careful and thorough preoperative evaluation of each individual patient is required to
Fig 3. A patient with acquired ptosis as shown preoperatively. properly correct ptosis. Factors to be addressed include4 the presence or absence of familial ptosis, age of onset, history of trauma, medications used by patient (topical and systemic), whether ptosis worsens with fatigue, and whether there are systemic illnesses that might be related to the ptosis. The first questions are asked to determine if the ptosis is congenital or acquired. This often can be determined by reviewing old photographs of the patient to determine if he or she has had ptosis from childhood or if it was recently acquired. General eye examinations, including measurement of visual acuity, ocular rotations, retinoscopy, and a dilated fundus examination, are conducted. The Schirmer test, a diagnostic test for dry eyes, also is performed to deter-
d+ 733
AORN JOURNAL
mine lacrimal function and adequacy of tear film. This test is conducted by placing a strip of filter paper in the conjunctival sac of the lower eyelid. This stimulates lacrimal gland secretions, The paper is left in place for five minutes with the patient’s eyes closed. The wet area on the paper is then measured. A wet area of 15 mm or more is considered normal, and a measurement of less than 15 mm is considered decreased tear production. Adequate tear function is imperative because the eyelid may not close completely after the ptosis correction. This could lead to dry eyes if tear function is not adequate. Therefore, if the ptosis does not impair visual acuity and there is no marked cosmetic deformity, the condition is best left alone. A key element in the preoperative evaluation is determining the amount of levator function. The surgical correction depends largely on the functional strength of the levator muscle. Levator function is determined by placing a ruler at the temporal side and asking the patient to look straight ahead, then all the way down. The zero point is noted at the edge of the closed upper lid. The patient then looks all the way up, and the position of the lid is noted on the ruler. The measurement may be up to 20 mm, and less than 10 mm is considered decreased levator function.
Preoperative Cure
P
atients exhibit many emotions and reactions upon learning that they must undergo a surgical procedure. Their principal concern is the success of the operation. The age of patients undergoing eye surgery varies, and each age group has specific needs. With outpatient surgery on the increase, the operating room staff members must not only meet each individual’s needs and provide care but also prepare the patient and family or friends for home care. Proper communication with the physician’s office is necessary to aid in coordination of care and teaching, which increase the efficiency and effectiveness of care. Levator aponeurosis repair is performed on 736
OCTOBER 1991, VOL 54, NO 4
an outpatient basis. The anesthesiologist and the admission observation and discharge (AOD) nurse conduct a preoperative visit the day before surgery or early the morning of surgery. The preoperative evaluation session helps educate patients and their family members. Explaining routine admission procedures helps relieve anxiety. The AOD nurse obtains pertinent medical information and witnesses the patient’s or parent’s signature on the informed consent form if it was not signed at the physician’s office. The anesthesiologist discusses the types of anesthesia, anesthetics and sedatives, and all necessary monitoring equipment. For adults, local infiltration anesthesia with monitored anesthesia care is the anesthesia of choice because patient cooperation is needed during the procedure. Preoperative medical assessment is important because it provides the anesthesiologist with a plan of preoperative management, an evaluation of risks, and a baseline determination of the patient’s condition. The patient’s family members and/or friends should be included in the teaching because their presence may help the patient better understand the planned procedure; they also provide support. The AOD nurse reviews and reinforces all verbal and written information and answers any questions. He or she reminds the patient not to eat or drink after midnight, unless his or her physician allows certain medications by mouth with a sip of water on the morning of surgery. The nurse reminds women not to wear makeup the day of surgery. Unless indicated by age or medical condition, no laboratory tests are ordered. On the day of surgery, the patient arrives at the AOD unit where the AOD nurse introduces himself or herself to the patient and family members. Family members of an adult patient go to the waiting area while parents of an infant or child stay with the patient until the circulating nurse is ready to take the patient into the operating room. The AOD nurse instructs the patient to remove all clothing and gives him or her a gown, hair covering, and booties to wear. The patient gives all valuables to a family
OCTOBER 1991, VOL 54, NO 4
AORN JOURNAL
Fig 4. Lid crease marked with incision line and skin retracted showing preaponeurotic fat pad. (Reprinted from “Evaluationand management of the ptosis patient, R Waller, C D McCord, M Tunenbaum, Oculoplastic Surgery, second ed (1987),C D McCord, M Tanenbaum, eds, with permission from Raven Press, New York City)
Fig 5. Sutures placed on nasal, central, and temporal edges of aponeurosis. Sutures attached to anterior-superiortarsus. (Reprintedfrom “Evaluationand management of the ptosis patient, R Waller, C D McCord, M Tanenbaum, Oculoplastic Surgery, second ed (1987), C D McCord, M Tunenbaum, eds, with permissionfrom Raven Press, New York City)
member or puts them in the hospital safe at the admitting office. The nurse then assists the patient onto a stretcher and puts a warm blanket on him or her for comfort. An anesthesiologist or nurse anesthetist starts an IV line providing lactated Ringer’s solution. The circulating nurse and the scrub nurse prepare the operating room according to the surgical procedure planned and the surgeon’s preferences. When the room is ready, the circulating nurse greets the patient in the AOD unit and introduces himself or herself and other members of the surgical team. He or she makes another preoperative assessment based on the preoperative evaluation documented by the AOD nurse. The circulating nurse explains
operating room routine, answers any questions, and ensures that the patient is comfortable and understands the procedure. While still in the AOD unit, the surgeon marks the patient’s lid creases and any excess skin with toothless forceps and a marking pen. The drawing identifies the incision lines before the tissues are distorted by local anesthetics. Children’s lids usually are marked after they are asleep. The nurse informs the patient that he or she may be asked to move to a semi-sitting position during the procedure. The patient may be asked to look straight ahead, up, or down to fully elevate the eyelids. This is necessary for the surgeon to make adjustments to the eyelid contour
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AORN JOURNAL
and height. Long, split drapes maintain sterility as the patient sits up.
Intraoperative Care
T
he circulating nurse and the anesthesiologist or nurse anesthetist bring the patient to the operating room and assist in the safe transfer of the patient to the OR bed. The patient is placed supine in a slight reverse Trendelenburg position. The nurse secures the safety strap across the patient’s thighs and pads elbows and heels. He or she attaches monitoring equipment for vital signs, electrocardiogram, and oxygen saturation. The patient’s arm closest to anesthesia is placed on Fig 6. Sutures are tied permanently and skin incision closed. an armboard; the opposite arm is Cross-section view shows suture placement. (Reprinted from loosely restrained at the wrist “Evaluation and management of the ptosispatient, R Walter, C and tucked securely by the D McCord, M Tanenbaum, Oculoplastic Surgery, seconded patient’s side. The nurse also (1987), C D McCord, M Tanenbaum, eds, with permission from ensures that the patient is warm Raven Press, New York City) and comfortable and provides emotional reassurance as needmizes tissue distortion caused by the injected ed. The circulating nurse prepares a mixture of drug. The epinephrine in the lidocaine prolongs the local anesthetic that the surgeon injects the analgesia, decreases the rate of systemic before skin preparation. The local injection is a absorption, and enhances hemostasis. Because mixture of % mL of 1% lidocaine hydrochlopatient safety and comfort are priorities, the ride with 1:100,000 epinephrine and 4% mL of smallest amount of local anesthetic that has the bacteriostatic sodium chloride. It is injected desired effect is used. Proparacaine and tetrawith a 5-mL syringe and a 30-gauge, %-inch caine hydrochloride 0.5% ophthalmic solutions needle. This diluted anesthetic numbs the skin (topical anesthetics) are instilled into the eye. without burning and allows a painless injection The circulating nurse prepares the patient’s of the full strength anesthetic that follows. skin by washing the entire face and upper neck, The next injection contains a half-and-half including the oxygen nasal cannula. The prep mixture of 2% lidocaine hydrochloride with solution is povidone-iodine and is washed off 1:100,000 epinephrine and hyaluronidase and completely with sterile saline. The nurse 0.75% bupivacaine hydrochloride in a 12-mL explains the skin prep as he or she proceeds and syringe with a 30-gauge, %-inch needle. One to reminds the patient to keep his or her eyes 2 mL is injected into the eyelid to be corrected. closed to prevent any prep solution from enterMore may be given during the procedure if the ing the eyes. patient experiences any discomfort. The The scrub nurse and the surgeon drape the hyaluronidase increases dispersion and mini”
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The surgeon places the patient with a head drape, a suture bites in the anteriortowel across the chest, and a superior tarsus and through large split sheet with the the aponeurosis, initially edges going around the using temporary or slip patient’s head. The circulatknots. The patient is asked to ing nurse also gives the scrub nurse local anesthetic for the look up or down and may be assisted to a sitting position back table in case additional by the circulating nurse and local infiltration is needed the anesthesia personnel. during the procedure. The surgeon places a sponge Fig 7. The surgeon places suture at Restraints andlor straps are soaked in cool saline over the the central edge of the aponeurosis. temporarily loosened to allow the patient to sit up unoperative eye to shade it comfortably while adjustf roin the bright over h e ad ments are made. In cases that require general lights. anesthesia (eg, congenital cases in children), The drooping eyelid is elevated by repairing, the aponeurotic tendon is advanced approxishortening. or advancing the levator aponeurotmately 3 to 4 mm for each millimeter of ptosis ic tendon. With a #1S blade, the surgeon makes present preoperative1y .5 an incision at the previously marked lid crease and follows with careful dissection to minimize When the eyelid is at the desired height, the sutures are tied permanently (Fig 6). The tentissue trauma. don is not cut or resected. One end of the tenA bipolar cautery is used for hemostasis because it can be used in a dry or wet area and don is attached to the anterior-superior portion of the tarsus. The skin edges are sometimes causes minimal patient discomfort and tissue sutured to the aponeurosis (with a skin-aponeudamage. The surgeon gently retracts the skin rosis-skin bite) to create a better lid crease. The with small. double-pronged skin hooks and surgeon closes the remainder of the skin with trims the preaponeurotic fat pads as necessary (Fig 4). The surgeon asks the patient to look up interrupted or running suture (Fig 7). or down so he or she can find the aponeurosisThe only dressings required are topical opha mobile. white, glistening tendon. The surgeon thalmic ointments. One ointment is a combinaplaces 6-0 nylon suture at the nasal. central, and tion steroid/antibiotic for the wound, and another is a lubricant for the eye. The nurse applies temporal edges of the aponeurosis and either eyepads soaked in iced saline over the eyelids. reattaches or advances the tendon (Fig 5).
Fig 8. A patient with acquired ptosis before surgical correction (left) and the same patient shown one week postoperatively (right). 740
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He or she gives the remaining bottle of iced saline to the patient for home ice compresses.
Postoperative Care
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fter the procedure, the circulating nurse and the anesthesia personnel take the patient back to the AOD unit for observation. Both give a report to the AOD nurse. In cases where general anesthesia is used (usually children), patients are taken to the postanesthesia care unit before they are taken back to the AOD unit. The nurse in the recovery area applies ice compresses over the eyelids to control bleeding and swelling, which is minimal. The head of the bed is kept elevated for the same reason. When the patient is stabilized, the nurse reviews and reinforces postoperative instructions. Diet. The patient can resume eating gradually except for hot liquids, which are contraindicated for at least 24 hours to prevent vasodilation and bleeding. Activities. The patient can resume normal activity gradually but should avoid strenuous activities (eg, bending, heavy lifting). Showering is allowed. The nurse advises the patient to sleep with an extra pillow under his or her head. Medication. All previous medications are resumed and the surgeon orders a prescription for pain and discomfort (usually hydrocodone/ acetaminophen). Aspirin should be avoided. The patient lubricates the eye at bedtime with a topical ointment (eg, ocular lubricant, neomycinpolymycin-dexamethasone ointment). Ice compresses. The patient is advised to apply ice compresses every hour while awake for 15 to 20 minutes for the first 48 hours. Follow-up visit. The patient makes an appointment to return to the physician’s office the next day. Patients also are instructed to call if they experience severe pain in or behind the eye or notice a marked change in vision. The surgeon usually calls the patient at home the night after surgery to ask if he or she has any problems or questions. When the patient is stable as assessed by the
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anesthesiologist, the AOD nurse proceeds with discharge procedures. Figure 8 shows a patient with acquired ptosis before and after surgical correction.
Conclusion
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o properly manage ptosis, the etiology must be assessed. In recent years, more thorough understanding and knowledge of the anatomy and physiology of the eyelid have led to more conservative approaches to correct the pathophysiology. Needless sacrifice of healthy eyelid tissue, which may interfere with tear function, can be avoided. As with any other type of surgical procedure, there are risks and complications involved in levator aponeurosis repair. The most common and easily corrected complications are overcorrection and undercorrection, which occur only occasionally in experienced hands. Another possible complication is lid asymmetry, which can result from sutures that are too tight. Other rare and some relatively minor complications reported are postoperative hemorrhage, lid infections, keloid formation, and mild suture granuloma. The success rate is determined by what one is willing to accept as a good result.6 r: Notes 1. R Waller, C D McCord, M Tanenbaum, “Evaluation and management of the ptosis patient,” Oculoplastic Surgery, second ed, C D McCord, M Tanenbaum, eds (New York City: Raven Press, 1987) 333. 2. Ibid, 330. 3. Ibid, 334. 4. Ibid,332. 5. A J Berlin, K P Vestal, “Levator aponeurosis surgery: A retrospective review,” Ophthalmology 96 (July 1989) 1033-1036. 6. Ibid, 1035. Suggested reading Boyd-Monk, H; Steinmetz 111, C G. Nursing Care of the Eye. Norwalk, Conn: Appleton & Lange, 1987. Vaughan, D; Asbury, T; Tabbara, K F, eds. General Ophthalmology, twelfth ed. Norwalk, Conn: Appleton & Lange, 1989. 741