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British Oculoplastic Surgery Society (BOPSS) National Ptosis Survey
  1. E Scoppettuolo1,
  2. V Chadha2,
  3. C Bunce3,
  4. J M Olver4,
  5. M Wright2,
  6. on behalf of BOPSS
  1. 1
    Sussex Eye Hospital, Eastern Road, Brighton, UK
  2. 2
    Princess Alexandra Eye Pavilion, Chalmers Street, Edinburgh, UK
  3. 3
    Research and Development, Moorfields Eye Hospital, London, UK
  4. 4
    Western Eye Hospital, 171 Marylebone Road, London, UK
  1. Dr M Wright, Princess Alexandra Eye Pavilion, Chalmers Street, Edinburgh EH3 9HA, UK; mark.wright{at}luht.scot.nhs.uk

Abstract

Aim: To assess the results of primary aponeurotic ptosis surgery among UK ophthalmic oculoplastic surgeons, from both the surgeon’s and patient’s perspective; also to inform and encourage good clinical practice by generating outcomes for individual surgeons, units and for benchmarking purposes.

Methods: A prospective, web-based, non-comparative, interventional study was conducted over a period of 1 year commencing January 2005 and ending December 2005. The data-entry sheet for the preoperative, operative and postoperative data was completed and submitted online via the British Oculoplastic Surgery Society website. Surgical results were assessed objectively (by the surgeon) by measuring the upper lid margin reflex distance (uMRD) and the interlid difference in: MRD, lid show, skin crease and lid contour with the outcome graded as: success, partial success or failed. Surgical results were also assessed subjectively (by the patient) with the outcome graded as: completely satisfied, significantly improved, no change or worse than before the operation.

Results: Three hundred and sixty-five patients undergoing primary aponeurotic ptosis repair, from 40 different consultant-led teams with a declared oculoplastic interest and expertise, originating from 27 units across the UK were entered into the study. Using objective criteria, success was achieved in 128/223 (57%) cases, with significantly greater degrees of success seen in patients with mild ptosis and for surgeons who performed ptosis surgery more frequently. Using subjective criteria, 184/282 (65%) of patients were completely satisfied, with a further 89/282 (32%) judging themselves significantly improved. The patients’ assessment of the surgery was less critical than that of the surgeons: 46/138 (33%) of patients who were completely satisfied and 37/72 (51%) of those who were significantly improved did not meet the criteria for a successful surgical outcome. The re-operation rate was 8/313 (2.6%).

Conclusions: The authors have generated a valid series of surgical outcomes both for individuals, units and the UK as a whole, expressed in both objective and subjective terms for what we regard as the signature procedure for an oculoplastic surgeon: aponeurotic ptosis surgery. Individual results have been communicated to our members, which will allow them to compare their results with true peer-group-generated figures and will aid appraisal and ultimately revalidation.

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The General Medical Council’s (GMC) publication “good medical practice” emphasises the importance of audit.1 Robust and reliable clinical outcome measures are required for consultant appraisal and revalidation. Our perception was that despite the existence of several well-conducted aponeurotic ptosis surgery publications,216 these papers reflect the experience of a single or small group of surgeons and that the success rates quoted may not be the most appropriate figures for any individual surgeon to compare their results to in the UK. As the significant majority of UK ophthalmic oculoplastic surgeons are members of the British Oculoplastic Surgery Society (BOPSS), we feel that the study reflects the typical outcome of patients being treated for primary aponeurotic ptosis in UK ophthalmic units. Given the difficulties of recruiting surgeons from outwith BOPSS, it also strikes a balance between maximising the number of patients recruited while keeping the quality of the preoperative and postoperative data intact. The main aim of our study was to assess the results of primary aponeurotic ptosis surgery among UK ophthalmic oculoplastic surgeons, from both the surgeon’s and patient’s perspective; also to inform and encourage good clinical practice by generating outcomes for individual surgeons, units and benchmarking purposes.

PATIENTS AND METHODS

During a 1-year period between January 2005 and December 2005, patients with aponeurotic ptosis undergoing primary surgery by a member of the BOPSS were recruited, and the data were submitted online via the (BOPSS) website. The data-entry sheet for the preoperative, operative and postoperative data was available to download from the BOPSS website. Measurements included: upper margin reflex distance (uMRD), defined as the distance from the central corneal light reflection to the upper lid margin; lid show, defined as the distance between the upper lid margin and the upper lid skin fold and which directly correlates with the degree of dermatochalasis; skin crease and levator function. Ptosis was graded as mild (uMRD greater than or equal to 2 mm), moderate (uMRD = 1 mm) or severe (uMRD = 0 mm). Surgical details including: type of surgical approach; suture material; number of sutures placed in the aponeurosis and type (ie, adjustability); associated blepharoplasty and type of anaesthesia were recorded. Seniority of surgeon (consultant, fellow, associate specialist/staff grade, specialist registrar and senior house officer) and setting: location of surgical unit and whether this was a National Health Service (NHS) hospital (free healthcare hospitals) or private practice was also noted. Outcome criteria were assessed by the surgeon and, if possible, a second medical observer 3 months postoperatively and, if bilateral, 3 months after the second side. The patient was asked by an independent observer (a non-clinical member of the team, often a medical secretary) about their perception of the outcome. Complications, both per-operative and late, were noted. When the data were uploaded (all patients gave their consent) the objective outcome of the surgery was calculated automatically according to the criteria (suggested by the BOPSS audit committee, MW and JO, and subsequently agreed by the members) below, and the surgical results were graded as a success, suboptimal or failed. The patient’s perception of the outcome was also entered according to the criteria below. If redo surgery was performed, the reasons for this were documented. At all times, the confidentiality of each surgeon’s results was maintained.

Inclusion criteria

Inclusion criteria were NHS and privately operated adult patients (over 16 years) undergoing primary surgery under either local or general anaesthesia for aponeurotic ptosis (high skin crease with normal levator function; defined as >12 mm), with or without blepharoplasty.

Exclusion criteria

Exclusion criteria were non-aponeurotic ptosis, aponeurotic ptosis with levator functions less than 12 mm and redo ptosis surgery; and keratopathy (including dry eyes) of sufficient severity to influence the postoperative lid height.

Surgical techniques

Surgeons were free to use whatever technique they felt most appropriate for each patient.

Outcome measures

Objective outcome

The operation was considered a success only if all the following criteria were simultaneously met: uMRD was between 3 and 5 mm; interlid MRD difference was 1 mm or less; interlid crease difference was 2 mm or less; interlid show difference was 2 mm or less; and there was a symmetrical lid contour present. The surgery was considered a partial success when any of the observations fell outside these measurements. It was considered a failure when the operation was judged to be a partial success and the operation was redone.

Subjective outcome

Patient satisfaction was graded as: completely satisfied, significantly improved, no change or worse than before the operation.

Statistical analysis

Spearman’s rank correlation coefficient was used to assess the significance of observed associations between outcome and ordinal study factors (eg, severity of ptosis) and between subjective and objective outcome. The Rank-Sum test was used to assess whether there was any association between outcome and surgical activity (>25 cases/year vs <11) and suture type (absorbable vs non-absorbable).

RESULTS

Three hundred and sixty-five patients were recruited from 40 consultant-led teams with contributions from 27 eye units across the UK. Ninety-one per cent of cases were NHS patients and 9% private patients. Data for 429 eyes of 365 patients were submitted online. Fifty-two cases were excluded: 49 had a levator function less than 12 mm (reminders of the inclusion and exclusion criteria were omitted from the data capture form during the early phase of the study period), and three cases included patients who were less than 16 years of age. Three hundred and thirteen patients were entered into the analysis. Unfortunately, only 2.5% of patients were assessed by a second medical observer during the study period. The age range was 18–94 years, median 67, and 59% were female. Sixty-three per cent of patients had unilateral ptosis and 37% bilateral. The severity of the ptosis was classified as mild in 30%, moderate in 34% and severe in a further 36%. Seventy-six per cent of surgical procedures were carried out by consultant surgeons, and 24% carried out under consultant supervision by training-grade ophthalmologists. The overwhelming majority of surgeons (87%) chose anterior approach levator aponeurosis advancement. Eight per cent performed conjunctivo-mullerectomy, 1% posterior approach aponeurosis advancement and 1% tarso-mullerectomies. In 3%, the surgical procedure was not stated. Three sutures were used to obtain the desired lid height and contour in 81% of patients undergoing aponeurosis advancement. Absorbable sutures were used in 81%, with only 15% undergoing an adjustable suture technique. Eighty-two per cent of patients had their operation carried out under a local anaesthetic.

The objective outcome data set was complete in 223/313 of patients. Applying our strict criteria above, 57% of patient’s operations (58% by consultants) were deemed to be a success. The reasons for partial success (39%) were predominantly due to an abnormality of postoperative lid height: (1) either absolute, the lid being too high >5 mm or too low <3 mm in 58/87 (67%); or (2) relative, with the interlid MRD difference being more than 1 mm in 30/87 (35%). The failure (re-operation) rate was 2.6%, and in all cases this was because of an unsatisfactory interlid MRD with 7/8 lids being too low. There was evidence of an association between success and preoperative severity of ptosis (p<0.001, fig 1).

Figure 1 Preoperative severity of ptosis and objective outcome (p<0.001).

The frequency of surgical activity was positively correlated with the objective outcome (fig 2).

Figure 2 Frequency of surgical activity and objective outcome (p = 0.039).

There was evidence of a better outcome with non-absorbable sutures when compared with absorbable sutures (fig 3).

Figure 3 Suture type and objective outcome (p = 0.04).

There was little evidence of any association between outcome and each of type of anaesthesia, number of sutures used or blepharoplasty (for both unilateral and bilateral surgery). The subjective outcome data set was complete in 282/313 patients. Patients rated their outcomes as follows: 65% completely satisfied (consultants 69%), 32% significantly improved, 2% no change and <1% worse. There was little evidence of any association between subjective outcomes and preoperative severity of ptosis (fig 4), the surgeon’s level of activity (fig 5), suture material (fig 6), number or type of anaesthesia or blepharoplasty.

Figure 4 Preoperative severity of ptosis and subjective outcome (p = 0.80).
Figure 5 Frequency of surgical activity and subjective outcome (p = 0.763).
Figure 6 Suture type and subjective outcome (p = 0.21).

When adjustable sutures were employed, the objective outcomes were significantly worse; paradoxically, the subjective outcomes were significantly better.

There was a positive correlation (p<0.001) when the objective and subjective assessments of the outcomes were compared, with patient satisfaction levels exceeding that of the surgeons (table 1).

Table 1 Correlation between objective and subjective outcomes (the figures only include data from those patients in whom the objective and subjective outcomes data sets were both complete)

Thirty-three per cent of patients who were completely satisfied and 51% of those who were significantly improved did not meet the criteria for a successful surgical outcome. Conversely, one patient rated their outcome worse than before the operation despite objectively meeting the success criteria.

There were 0.3% (one case) of complications: wound dehiscence, wound infection and haematoma.

DISCUSSION

The key aspect of the appraisal process is to encourage every doctor to reflect upon their performance and to ask themselves whether it matches that of their peers. Standards for audit should be based on the best available evidence. We believe that we have generated a valid series of surgical outcomes expressed in both objective and subjective terms for what is regarded as the signature procedure for an oculoplastic surgeon. Oculoplastic surgery outcomes are inherently less objective and therefore less “measurable” than the majority of other ophthalmic subspecialties. This, however, does not constitute a reason for not trying to facilitate the audit of one of our most commonly performed procedures.

Criteria of success and patient selection

The biggest difficulty in comparing success rates is that the outcome criteria and patient selection are variable. Also, the number of patients in some studies is small, and most studies are retrospective. Very few studies include pure, primary, good-function aponeurotic ptosis.39 Very strict criteria of success were chosen based upon our perception of a good result and which were tempered by criteria often quoted in the existing literature.516 We have therefore chosen to compare our objective results with others in terms of lid height, as this is the most commonly quoted reason for a suboptimal result and also for redo surgery. Re-operation rates are less useful, as the decision to re-operate is dependent upon multiple surgeon and patient factors, but are included for completeness.

Objective comparisons of success

Using criteria of uMRD of 2–4.5 mm and an interlid MRD difference of 1 mm, success rates of between 71%5 and 74%14 (the latter dropping to 61% 2–4 months postoperatively) have been reported. Most recently, Freuh and co-workers15 quoted a success rate of 61% with a maximum acceptable interlid difference of only 0.5 mm and uMRD of 2–4 mm. The re-operation rates for each of these three studies ranged from 8.7% to 31%. None of these studies included the position of the lid crease or degree of lid show in their criteria of success. These factors are of clinical importance, as significant postoperative asymmetry in either will significantly impair the aesthetic aspect of the outcome, and are likely to result in lower levels of patient satisfaction. Ben Simon et al included an assessment of lid position, eyelid contour and crease, with no more than 1 mm difference being assessed as an excellent outcome, and quoted a success rate of 43%.16

Subjective comparisons of success

Our outcomes are better than those quoted by Taherian et al,17 the only other study which has analysed the outcome of ptosis surgery from the patient’s perspective. While the subjective criteria of success we chose differed slightly from this study, the difference in outcomes is explained by comparing the patient groups. Taherian’s retrospective study included multifactorial causations of ptosis, generating more complex, for example brow suspension, and also included redo surgery. Both studies demonstrated a statistically significant positive correlation when the objective and subjective success rates were compared.

Some authors feel that the re-operation rate is a measure of patient satisfaction; others note that a patient with more severe preoperative blepharoptosis may deem under-correction acceptable.5 While the preoperative severity of ptosis affected the objectively assessed outcome, we found very little difference (66–70%) in the subjective patient satisfaction levels. Our results therefore support the assumption that patients with more severe degrees of ptosis preoperatively are more accepting of a less-than-perfect result.

Surgical technique

Our findings that anterior approach aponeurosis advancement was used in 87% of our procedures and that 82% of procedures were carried out under local anaesthesia are in keeping with the weight of the literature.316 As the numbers of patients in whom different surgical approaches were employed were small, we do not feel that any useful conclusions can be drawn in terms of deciding which procedure is most effective.

Weaknesses of this study

The main weaknesses of our study were that we only managed to recruit 53% of BOPSS members and that in 29% of patients, our data sets were incomplete. Our study population represented 17% of all ptosis corrections performed UK-wide during the same period (personal communication (MW) with the Department of Health and Scottish Health Service Statistical Department). Despite enlisting the help of the Department of Health and Scottish Health Service statistical department, we found it very difficult to establish an accurate estimate of the numbers of aponeurotic ptosis surgery performed in the UK over the time period of the study. Our figure of 17% is almost certainly an underestimate. We tried to strike a balance between obtaining a significant amount of information to enable us to answer as many questions as possible while not discouraging busy clinicians. All studies where the surgeon acts as judge and jury in terms of the outcome are inherently open to criticism; we tried to circumvent this weakness, but in only 2.5% of the cases was a second observer able to be recruited reflecting the time pressures in NHS clinics. We decided upon telephone surveys conducted by a non-clinical member of the team rather than postal questionnaires. While this decision maximised the patient’s response rate, we accept it may have induced a positive bias with respect to the patient’s replies. Finally, by including all cases of aponeurotic ptosis, a (relatively) small number of cases of contact lens induced ptosis have been included in the study population, the majority of who have involutional (aponeurotic) ptosis.

CONCLUSION

Our study has answered the questions asked of it. First, using the objective and subjective criteria described above, 57% of patients undergoing primary aponeurotic ptosis surgery by UK oculoplastic surgeons had a successful outcome with 65% of patients being completely satisfied. Second, BOPSS members can assess how their individual results compare with their peers. Lastly, we have demonstrated a strong positive correlation between the surgeon’s and patient’s assessment of the outcome. Our plan is to apply these voluntary online surveys to other oculoplastic surgical procedures to facilitate future audits. This was our first on-line survey, and our hope would be for increased participation levels with perhaps, in the future, collaboration with other oculoplastic colleagues both in the UK and overseas.

Acknowledgments

BOPSS membership and especially Maarten Tryuens our webmaster.

REFERENCES

Footnotes

  • Competing interests: None.

  • Patient consent: Obtained.

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