Bartley G B, Lowry J C, Hodge D O
Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA.
Trans Am Ophthalmol Soc. 1996;94:165-73; discussion 174-7.
Blepharoptosis repair by levator advancement is successful in most instances, but the postoperative eyelid level is not uniformly predictable. This study was undertaken to evaluate the possible effect of epinephrine (from local anesthetic) on eyelid position.
Seventeen adults with acquired unilateral ptosis as a result of levator aponeurosis dehiscence underwent levator aponeurosis advancement. The distance between the upper eyelid margin and the central corneal light reflex was measured preoperatively with the patient in both the upright and the supine position, 10 minutes after injection of 1.0 mL of anesthetic solution (2% lidocaine with 1:100,000 epinephrine and 12 U hyaluronidase per mL) in the supine position, intraoperatively after skin closure in the supine position, and 1 week or more postoperatively in the upright position. The ptotic lid was positioned intraoperatively in relation to the contralateral unoperated lid according to the change (presumably) induced by epinephrine stimulation of Müller's muscle.
Eleven (65%) of the 17 patients had final postoperative lid positions within 1 mm between eyes. Two patients (12%) had undercorrection. Four patients (24%) had overcorrection by > 1 mm. The overcorrected lids were satisfactorily positioned, however, and none required further surgery; in 3 of these 4 patients, the unoperated lid had become ptotic, probably as a result of Hering's law. Differences between operated and unoperated lids and between the different times of measurement were analyzed. Significant changes in lid position occurred in the ptotic lids after injection (mean, +1.1 +/- 1.5 mm; median, +1.0 mm; P = .004) and in the final intraoperative difference between operated and unoperated lids (mean, +0.8 +/- 0.9 mm; median, +1.0 mm; P = .003). The change in the unoperated lid from preoperative upright to preoperative supine was significantly greater in the 6 failures (mean, -0.8 +/- 0.6 mm; median, -1.0 mm) than in the 11 successful outcomes (mean, +0.1 +/- 0.8 mm; median, 0.0 mm; P = .03). The change in unoperated lid position after injection of the ptotic lid was significantly greater in the failures (mean, +0.4 +/- 0.5 mm; median, +0.3 mm) than in the successful cases (mean, -0.2 +/- 0.4 mm; median, 0.0 mm; P = .02).
Although it seems intuitively reasonable and clinically appropriate to account for the stimulatory effect of epinephrine during ptosis surgery, such intraoperative compensation alone did not yield a universally successful outcome in this study.
提上睑肌缩短术修复上睑下垂在大多数情况下是成功的，但术后眼睑水平并非始终可预测。本研究旨在评估肾上腺素（来自局部麻醉剂）对眼睑位置的可能影响。
17例因提上睑肌腱膜裂开导致后天性单侧上睑下垂的成年人接受了提上睑肌腱膜缩短术。术前在患者直立位和仰卧位测量上睑缘与中央角膜反光之间的距离，仰卧位注射1.0 mL麻醉溶液（每毫升含2%利多卡因、1:100,000肾上腺素和12 U透明质酸酶）10分钟后测量，仰卧位皮肤缝合后术中测量，以及术后1周或更长时间直立位测量。术中根据肾上腺素刺激米勒肌（推测）引起的变化，将下垂眼睑相对于对侧未手术眼睑进行定位。
17例患者中有11例（65%）术后双眼睑最终位置相差在1 mm以内。2例患者（12%）矫正不足。4例患者（24%）矫正过度超过1 mm。然而，矫正过度的眼睑位置令人满意，无一例需要进一步手术；在这4例患者中的3例中，未手术眼睑出现下垂，可能是由于赫林定律。分析了手术眼睑与未手术眼睑之间以及不同测量时间之间的差异。注射后下垂眼睑的眼睑位置发生了显著变化（平均值，+1.1±1.5 mm；中位数，+1.0 mm；P = 0.004），手术眼睑与未手术眼睑在术中最终差异也显著（平均值，+0.8±0.9 mm；中位数，+1.0 mm；P = 0.003）。6例手术失败患者未手术眼睑从术前直立位到术前仰卧位的变化（平均值，-0.8±0.6 mm；中位数，-1.0 mm）明显大于11例手术成功患者（平均值，+0.1±0.8 mm；中位数，0.0 mm；P = 0.03）。下垂眼睑注射后未手术眼睑位置的变化在手术失败患者中（平均值，+0.4±0.5 mm；中位数，+0.3 mm）明显大于成功病例（平均值，-0.2±0.4 mm；中位数，0.0 mm；P = 0.02）。
虽然在睑下垂手术中考虑肾上腺素的刺激作用在直观上似乎合理且临床上合适，但在本研究中仅这种术中补偿并未产生普遍成功的结果。
