• Vol. 36 No. 10, S22–S26
  • 15 October 2007

The Role of Muller’s Muscle-Conjunctiva Resection (MCR) in the Treatment of Ptosis



Introduction: Muller’s muscle-conjunctival resection (MCR) is a form of posterior approach surgery for the treatment of ptosis. The phenylephrine test is commonly used preoperatively to predict the treatment response of MCR and to guide the amount of Muller’s muscle resection needed. Methods: Literature search for this topic is done with PubMed using the words “Muller’s muscle”, “conjunctival”, “resection”, “mullerectomy”, “ptosis” and “blepharoptosis”. Additional articles on this subject were traced when indicated from the list of literature obtained by the PubMed search engine. Results: The original surgical technique of MCR reported by Putterman and other modifications of this surgical technique are described. Various treatment algorithms on the quantity of Muller’s muscle to be resected for a desired level of ptosis correction and the surgical success rates are reviewed. As compared to other common ptosis surgeries, it offers the advantages of tarsal preservation, avoiding skin incisions, non-violation of the orbital septum and orbital fat. The disadvantages of MCR include non-preservation of conjunctiva (with goblet cells) and damage to the accessory lacrimal glands (glands of Krause and Wolfring). Conclusions: MCR is an acceptable alternative treatment modality for mild and moderate ptosis with good levator function. It offers the benefits of short surgical time, being less invasive, obviating the need for intraoperative adjustment, predictability and less re-operation. The potential risks of conjunctival forniceal shortening and dry eye after surgery seem to be low.

The Muller’s muscle (MM) is a sympathetically innervated upper eyelid muscle that elevates the eyelid besides the levator palpebral superioris. The MM resembles smooth muscle and originates from the levator aponeurosis about 15 mm above the superior tarsus.1 The MM is adherent to the conjunctiva but easily separable from the levator aponeurosis and is enclosed in a vascular sheath. The lifting effect of the MM is best demonstrated clinically by the improvement of some ptotic eyelids upon stimulation with phenylephrine eye drops (phenylephrine test, Fig. 1).

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