Shortened Fornix Syndrome After Posterior-Approach Ptosis Repair

Marissa K Shoji; Eman Al-Sharif; Catherine Y Liu; Bobby S Korn; Don O Kikkawa

doi:10.1097/IOP.0000000000002866

Shortened Fornix Syndrome After Posterior-Approach Ptosis Repair

Ophthalmic Plast Reconstr Surg. 2024 Dec 20. doi: 10.1097/IOP.0000000000002866. Online ahead of print.

Authors

Marissa K Shoji¹, Eman Al-Sharif^{1

2}, Catherine Y Liu¹, Bobby S Korn¹, Don O Kikkawa¹

Affiliations

¹ Division of Oculofacial Plastic and Reconstructive Surgery, Shiley Eye Institute, UCSD, La Jolla, California, U.S.A.
² Surgery Department, College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia.

PMID: 39704285
DOI: 10.1097/IOP.0000000000002866

Abstract

Purpose: To describe and characterize shortened fornix syndrome (SFS), a rare complication following posterior-approach ptosis repair using conjunctival Müller muscle resection.

Methods: This retrospective case series evaluates 4 patients who developed SFS after conjunctival Müller muscle resection. Clinical characteristics, surgical histories, management, and outcomes are reviewed.

Results: A total of 4 patients (2 females, 2 males; aged 61-74 years old) presented with ptosis associated with fornix shortening and symblepharon following conjunctival Müller muscle resection performed at outside hospitals. Potential contributing factors included intraoperative complications and multiple posterior-approach surgeries. Management strategies varied, including 5-fluorouracil and triamcinolone injections into the symblepharon, ocular surface reconstruction with symblepharon lysis and amniotic membrane grafting, and external levator advancement. All patients showed improvement in the SFS and eyelid height with treatment.

Conclusion: SFS, characterized by symblepharon, fornix shortening, and associated functional issues including ptosis and restricted eye movements, is a rare but significant complication of posterior-approach ptosis repair. Only one prior report has documented a similar entity in patients after conjunctival Müller muscle resection using glaucoma drops; interestingly, our cases occurred in patients without significant ocular surface or topical ocular medication use, suggesting SFS can develop independently of such treatments. Prevention strategies include meticulous intraoperative technique and a cautious approach to large resections or repeat posterior-based surgeries, with consideration of anterior-based techniques if appropriate. Management of SFS via a staged approach involving ocular surface reconstruction followed by anterior-based ptosis repair may lead to satisfactory outcomes. Awareness of this complication is crucial for proper patient selection and management of ptosis.