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blepharoptosis
The document is a comprehensive review on blepharoptosis, detailing its anatomy, classification, evaluation methods, and treatment options. It discusses various forms of ptosis, including congenital, acquired, and neurogenic cases, along with clinical measurements essential for diagnosis. Treatment strategies are emphasized based on the degree of ptosis and levator muscle function, highlighting surgical options such as levator resection, Müller’s muscle shortening, and brow suspension.
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blepharoptosis
- 1. -PTOSIS-Panit Cherdchu, M.D. PMKOphthalmology Department
- 2. “Blepharoptosis is amore accurate term than ptosis alone”
- 3. OUTLINE REVIEW ANATOMY HOW TOAPPROACH PTOSIS THE DISEASES Treatment TAKE HOME MESSAGE OUTLINE
- 4.
- 10. HOW TO APPORACHPTOSIS
- 11. Evaluation • History taking •Physical Exam • Additional Considerations • Ancillary Tests
- 12. 5 clinical measurement •Margin-reflex distance • Vertical palpebral fissure height • Upper eyelid crease position • Levator Funtion (upper lid excursion) • Presence of lagophthalmos
- 14. Margin-reflexdistance • MRD1 :distance from the upper eyelid margin to the corneal light reflex in primary position • MRD2 : distance from the lower eyelid margin to the corneal light reflex in primary position • MRD1=Single most important measurement • MRD1+MRD2=Palpebral fissure
- 15. VerticalPalpebralFissure • Widest pointbetween the lower eyelid and the upper eyelid • Patient is fixing on a distant object in primary gaze
- 16. UpperEyelidCreasePosition • Distance fromthe upper eyelid crease to eyelid margin is measured • Insertion of fibers from the levator muscle into the skinupper eyelid crease • 8-9 mm in males and 9-11 mm in females • Upper eyelid crease is typically lower or obscured in the Asian eyelid, with or without ptosis
- 18. Levator Function • Uppereyelid excursion from downgaze to upgaze with frontalis muscle function negated
- 19. Lagophthalmos • Note thegap between the eyelids in mm • Record the tear film quantity and quality
- 20. Additional Considerations • Headposition • Chin elevation • Brow position • Brow action in attempted upgaze • Tear film quantity and quality • Bell phenomenon • Synkinesis • The position of the ptotic eyelid in downgaze (palpebral fissure in downgaze) • Visual function and refractive error • Pupillary examination • External examination
- 21. Ancillary Test • Visualfield testing with the eyelids untaped vs taped improvement indicates better vision with eyelid surgery • Pharmacologic testing, pupillary evaluation in light and dark, reverse ptosis of the lower eyelid
- 22. Classification of TheDiseases
- 23. PTOSIS BY COURSE Traumatic MechanicalMyogenic Aponeurotic Neurogenic BY ONSET CONGENITAL Acquired Classification
- 24. MYOGENIC • Congenital vsAcquired • Congenital myogenic ptosis results from dysgenesis of the levator muscle • Fibrous or adipose tissue is present in the muscle belly • Diminishing the ability of the levator to contract and relax
- 25. characteristic • Decreased levatorfunction • Lid lag • Lagophthalmos • Upper eyelid crease is often absence or poorly formed
- 26. • Congenital myogenicptosis associated with a poor bell phenomenon or with vertical strabismus indicate concomitant maldevelopment of the superior rectus and levator muscles (monocular elevation deficiency, formerly, double-elevator palsy)
- 28. • Acquired myogenicptosis results from localized or diffuse muscular disease such as muscular dystrophy, chronic progressive external ophthalmoplegia (CPEO), MG, or oculopharyngeal dystrophy • Normal eyelid surgical correction is difficult • Frontalis sling +/- repair lower eyelid retraction and improve corneal protection
- 29. Aponeurotic ptosis • Acquiredaponeurotic ptosis is the most common form of ptosis • Stetching or dehiscence of the levator aponeurosis or disinsertion from its normal position • Common causes are involutional attenuation or repetitive traction on the eyelid • Frequent eye rubbing or prolonged use of rigid contact lenses • Exacerbated by intraocular surgery or eyelid surgery
- 31. characteristic • Highor absent upper eyelid crease secondary to upward displacement or loss of the insertion of the levator fivers into the skin • Thinning of the eyelid superior to the upper tarsal plate is often an association finding • Levator function is normal (12-15mm) • Worsen in downgaze • Limit the superior visual field
- 33. Neurogenic ptosis Congenital vsacquired
- 34. Congenital neurogenic ptosis •Innervation defects during embryonic development • Rare • Associated with congenital cranial nerve III palsy, congenital Horner syndrome, or the Marcus Gunn Jaw-winking syndrome
- 35. Congenital oculomotor nervepalsy • Ptosis+inability to elevate, depress, or adduct the globe • +/- dilated pupil • Treatment of the associated ptosis usually require a frontalis suspension procedure • Postopertive: lagophthalmos, poor ocular motility, and poor eyelid excursion, diplopia, exposure keratitis, and corneal laceration
- 36. Congenital Horner syndrome •Interrupted sympathetic nervous chain • Mild ptosis+miosis+anhidrosis+decreased pigmentation of iris on the involved side • Mild ptosis=innervational deficit muller muscle • Decreased sympathetic tone to the inferior tarsal muscle in the lower eyelid, the analoque of the muller muscle in the upper eyelid, results in elevation of the lower eyelid, also known as lower eyelid reverse ptosis
- 37. Congenital neurogenic ptosis •Synkinesis • Unilaterally ptotic eyelid elevates with jaw movements • Mother is the first witness • Aberrant connections between the motor division of CN V and the levator muscle
- 39. Acquired Neurogenic Ptosis •Interruption of normally developed innervation and is most often secondary to an acquired CN III palsy, to an acquired Horner syndrome, or MG Ischemic vs compressive
- 40. • Most commonis ischemic process which associated with DM,HT, arteriosclerotic disease • Ischemic acquired CNIII palsies do not include pupillary abnormality • Associated with pain • Resolve spontaneously with better LF within 3-6 months • If CNIII palsy+ pupillary abnormalityw/u compressive neoplastic or aneurysmal lesion • Treatment= frontalis suspension
- 41. Myasthenia gravis • Autoimmunedisorder • Ach receptors of NMJ • Most often generalized and systemic • Associated thymoma with positive chest CT finding • Surgical thymectomy results in improvement in 75% of case • Early manifestation involve ophthalmic, with ptosis,diplopia • TED occurs in 5%-10% of patients with MG
- 42. test • The acetylcholinereceptor antibody test • Edrophonium chloride (reverse with atropine) • The ice-pack test • Sleep or rest test • Single-fiber electromyography
- 43. TreatmentofMG • Response poorlyto systemic antichoinesterase alone • Add steroid=better outcome • Surgical must be delayed until medication fail at its maximum limit
- 44. MECHANICAL PTROSIS • Refersto the condition in which an eyelid or orbital mass weighs or pulls down the upper eyelid, resulting in inferior displacement • Plexiform neurofibroma • Hemangioma • Acquired neoplasm • Large chalazion • Postsurgical, posttraumatic edema • Etc…….
- 45. TRAUMATIC PTOSIS • Traumato levator aponeurosis or the levator muscle • Eyelid lacerations exposing preaponeurotic fat indicate the orbital septum has been transected and suggest possible damage to the levator aponeurosis
- 46. Pseudoptosis • Eyelid appearabnormally low in various conditions • Hypertropia • Enophthalmos • Micropthalmia • Anopthalmia • Phthisis bulbi • Superior sulcus defect secondary to trauma • Dermatochalasis
- 47.
- 48. TREATMENT 1. Levator aponeurosisrepair 2. Levator resection 3. Muller’s muscle shortening 4. Brow suspension
- 49. Key factor • Theamount of ptosis and the function of the levator muscle are the key factors • Levator resection is suitable for any amount of ptosis with a levator function better than 4 mm • Muller’s muscle shortening:The Fasanella-Servat operation was the first operation of this type. These operations are appropriate only if the levator function is at least 10 mm and there is a maximum of 2 mm of ptosis. The instillation of phenylephrine 10% (or 2.5%) will restore the affected lid to its normal position in suitable patients. • Brow suspension is the only procedure which will give a lasting correction if the levator function is 4 mm or less.
- 50. Consideration Procedure ofchoice LF>4mm Levator resection LF>10mm, ptosis<2mm, response to phrenylnephrine stimulation Muller’s muscle shortening LF<4mm Brow suspension
- 51. Levator Aponeurosis repair •Choice of approach to the levator The anterior (skin) approach is familiar, it allows skin to be excised and it leaves the conjunctiva intact. The posterior (conjunctival) approach, although less familiar at first, allows more postoperative control of the lid height. • Anterior vs Posterior levator aponeurosis repair
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- 57. Levator resection • Rememberthat levator resection can lead to change in height of eyelid within first 6 weeks • Rule of thumb lid may rise 1-2 mm if LF > 7 mm and may drop 1-2 mm if LF<7mm • Beard’s recommended figures for congenital ptosis give some guidance to predict final result of surgery
- 64. Muller’s muscle shortening •If phenylnephrine test is strongly positive ( restoring the affected lid to its normal position) Mullerectomy is highly recommended • 1.Measure MRD1 • 2.Instill phenylnephrine 10% into superior fornix of the eye with ptosis (If cardiac condition is presented phenylnephrine 2.5% may be used instead) • 3.Wait for 5 minutes • 4.measure MRD1 • If MRD1 improves after phenylnephrines test then this is positive result • And an improved MRD1 can indicate the length of muller’s muscle and conjunctiva to be resected
- 65. Type of responsesuggestion Normal level Resect 8 mm Higher than desired level Resect 6.5-8 mm Lower than desired level Resect 8-9.5 mm Little response or none Do something else
- 67. Muller’s muscle andconjunctiva shortening without tarsal plate excision (Open Technique)
- 69. Brow suspension • Children<4yrs FOX procedure (for later surgery if ptosis recur) • Older children and adults Crawford method • If unilateral ptosis bilateral brow suspension is still recommended to maintain indifferent movement • If one eye is good and one eye is not good weaken the one with good LF is suggested • Material= autogenous fascia lata is the best material when available • If not available silicone is prefered
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- 79. PTOSIS BY COURSE Traumatic MechanicalMyogenic Aponeurotic Neurogenic BY ONSET CONGENITAL Acquired Classification
- 80. Which operation isprefered? • Degree of ptosis is important • Levator function is also important
- 81. Ptosis Mild Phrenylnephrine test = positivemullerectomy Phrenylnephrine test = negative Fossanella blepharoplasty Levator resection moderate Levator resection Levator advancement severe Frontalis sling
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Editor's Notes
- #3 Ptosis is a common cause of reversible peripheral vision loss Many patients with ptosis report difficulty with reading
- #58 After levator aponeurosis or muscle resections the level of the eyelid may change during the fi rst 6 weeks. As a rule of thumb, the lid may rise by 1–2 mm if the levator function is >7 mm and may drop by 1–2 mm if it is <7 mm. The lid level can be expected to remain at its immediate postoperative level if the levator function is about 7 mm. In addition, the lid height may change a little from the level set at operation and that found at the fi rst dressing. The local anaesthetic injection and swelling of the tissues may distort the lid level at operation and the action of the orbicularis muscle, paralysed to a variable degree during the operation, may cause a small drop in the lid level postoperatively. These factors make it diffi cult to decide exactly where to set the lid at operation and how much levator to resect. Beard’s recommended fi gures for congenital ptosis give some guidance (Table 9.1). The aim is to achieve a lid level after operation of 1–3 mm from the upper limbus depending on the levator function. Other factors are relevant in a small number of patients.
- #65 These procedures are most effective if the phenylephrine test is strongly positive, restoring the affected lid to its normal position. Phenylephrine Test Phenylephrine is an alpha-1 adrenergic agonist that stimulates Muller’s muscle to contract. If the lid rises to its normal level in response to phenylephrine, Muller’s muscle shortening has been found to be more effective than if the response to phenylephrine is poor. Instil phenylephrine 10% into the superior fornix of the eye(s) with ptosis. Phenylephrine 2.5% may be used in the presence of suspected cardiac disease or uncontrolled hypertension. After 5 minutes assess the upper lid levels by comparing the MRD1 (margin–refl ex distance to the upper lid) pre- and post-phenylephrine. Symmetry at a good height indicates a good response to phenylephrine (Figs 9Ca,b). If lid elevation is inadequate repeat the dose of phenylephrine. A persistent inadequate elevation indicates a moderate or poor response (Figs 9Cc,d). The response of the lid height to phenylephrine offers a guide to the amount of Muller’s muscle and conjunctiva to be resected. If the lid corrects to a normal level, about 8 mm should be resected. If the lid rises higher than the desired level, reduce the resection to 6.5–8 mm. If the lid remains lower than the desired level, resect 8–9.5 mm. If there is little response, consider an alternative procedure such as a levator aponeurosis advancement/repair (9.2, 9.3), depending on the levatator function.
- #70 In young children (under 4 years) the Fox procedure (9.9) is chosen because any scarring from this initial operation will not interfere with later surgery if the ptosis recurs. In older children and adults the Crawford method (9.7) is preferred. A bilateral brow suspension is often recommended even though the ptosis is unilateral. If this is not done the difference in movement between the upper lids may be obviously asymmetrical postoperatively and less cosmetic. If, in addition, the levator function on the unaffected side is good it is advisable to weaken this levator (9.8) before inserting the suspension material. If this is not done the child may neglect to use the brow on the affected side, despite a bilateral brow suspension operation. Choice of brow suspension material Many different materials have been used for brow suspension. Autogenous fascia lata (see 2.19) is the best material when it is available. Stored fascia lata and most synthetic materials have a relatively high recurrence rate although an acceptably low level of complications such as infection and granuloma formation. Mersilene mesh and similar materials, for example expanded polytetrafl uoroethylene (Gore-tex), probably have a higher rate of exposure and granuloma formation and they are diffi cult to remove. Care must be taken to bury these materials deeply within the tissues, especially in the forehead. Children younger than about 3.5 years are too small for fascia lata harvesting. A synthetic material, for example silicone, is preferable until a defi nitive procedure is possible with autogenous fascia lata at about the age of 4. In adults with ocular myopathy, silicone is preferable to autogenous fascia lata because it can be removed easily if corneal exposure occurs.