Blepheroptosis
Dr.Harsh Amin
Applied Anatomy
Upper eyelid structure
Upper lid retractors:Levator aponeurosis
Aponeurosis Fans out forming
2 horns Also inserts into
orbicularis Lacrimal gland
around lateral horn
Upper lid retractors: Müller’s muscle
Müller’s muscle arises from undersurface of levator
They separate when lid is inverted
Oriental eyelid
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The fusion of L.apponeurosis with orbicularis is responsible for eye lid fold.
Disruption at this level is called levator dehiscence resulted in blunting of eye lid fold as in senescent eye.
Levator complex= LPS + aponeurosis + mueller m.
It is innervated by occulomotor nerve. The muller muscle is innervated by sympathetic
nerve.
Full excursion of lid approximates 10-15 mm and additiional 1-2 mm of elevation is provided by mullar muscle.
Surface Anatomy
Blepharoptosis
Drooping of upper eyelid below its normal
position (normal position 1-2mm of upper limbus) Midway between papillary aperture and
corneoscleral junction
Blepharoptosis - definition
Two types of ptosis: TRUE PTOSIS and PSEUDOPTOSIS.
True ptosis results from dysfunction of levator complex(LPS, levator
apponeurosis and muller muscle)
In pseudoptosis the lid is appeared to inferiorly displaced -- unrelated to levator complex as in enophthalmos.
Causes of pseudoptosis
Ipsilateral hypotropia Brow ptosis - excessive eyebrow skin
Dermatochalasis - excessiveeyelid skin
Lack of lid support Contralateral lid retraction
Classification
True ptosis
SyndromicMyasthenia gravisNeurofibromatosisHorner’s syndromeBlepherophimosis
Isolated Congenital- In congenital
ptosis scar tissue replacing the levator muscle fibre cause lagophthalmos
Aquired-Acquired ptosis may be due to levator dehiscence as in senescent eye and due to cataract ,trauma …(high or absent crease)
Evaluation
History Age Present since birth? Myogenic?
Worse when tired Neurogenic?
diplopia (III) ophthalmoplegic
migraine. Traumatic
ophthalmoplegia
Mechanical? Lumps Swelling (intermittent/
atopy) Trauma History Smoker/diabetic/drugs
(aspirin/warfarin) Dry eyes
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The nature of the lid fold should be qualified (sharp or blunted ) site - 7-9 mm above the ciliary margin. If the crease is blunted levator dehiscence from ant.lamellaAnd if sharp from post. lamella
We must test for lagophthalmos(esp. congenital cases) Presence and degree of lid lag- help in treatment
Orbicularis oculi muscle function checked (help in treatment)
Schirmer test for tear film coverage.
Proptosis B/L pupil and pupillary reflex should be evaluated to rule
out Horner syndrome. Marcus gunn jaw winking checked
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Position of upper eye lid is noted
Quantify and Classify ptosis (always on 2 different sittings)
Measure the levator function (always on 2 different sittings)
• Distance between upper and lower lid margins • Normal upper lid margin rests about 2 mm below upper limbus• Normal lower lid margin rests 1 mm above lower limbus• Amount of unilateral ptosis is determined by comparison
Vertical fissure height
Marginal reflex distance• Distance between upper lid margin and light reflex (MRD)
Distance between corneo-scleral junction n light reflex is measured
• Mild ptosis (2 mm of droop)
• Moderate ptosis (3 mm)
• Severe ptosis (4 mm or more)
• Reflects levator function
• Normal (15 mm or more)
• Good (12 mm or more)
• Fair (5-11 mm)
Upper lid excursion
• Poor (4 mm or less)
Examination – levator fatigue in myaesthenia
gravis
Look up without blinking for 30 secs Lids drooping to variable degree
Examination - jaw winking
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Grading of ptosis and levator function
Ptosis Levator function
Mild : 2-3mm Good : 10-15 mm
Moderate : 3-5mm Fair : 6-9 mmSevere : > 5mm Poor : < 5 mm
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Selection of correct operation
The degree of ptosis and extent of levator function determine the operative procedure.
The procedures includes ;
tarsal conjunctival mullerectomy levator advancement
levator plication Frontalis sling
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If the levator excursion is good (10-15mm) & Ptosis mild (2-3mm) - levator advancement levator plication tarsal cunjunctival
mullerectomy Ptosis moderate (3-5mm) - levator advancement levator plication Ptosis severe (>5mm) – levator advancement
If levator excrursion is fair (6-9) - levator advancement
If levator excrursion poor (>5mm) – frontalis sling
Post-traumatic: Wait 6 months for resolution then repair, unless child with risk of amblyopia
Timing
Contraindications
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Determine the etiology / Rule out pseudoptosis Patient counselled about intraoperative assistance.
LA-to assess intraoperatively LA- so mueller contaction – so over correction LA-use judiciously so anatomy not distorted Intraoperatively -Use Transparent Clear shields protect the eye & allow for
landmarks visualization Intraoperatively-dim lights to avoid reflexive squint
Vertical apex of lid created nasal to pupil margin Horizontal lead between light reflex n corneoscleral junction(if orbicularis m normal)
at pupil margin (if orbicularis abnormal)
Avoid shortening of lid and creating symptomatic lagophthalmos
All excisions must be parellel to lig margin to avoid tenting
No skin excision in secondary/tertiary procedures
Principles of repair
Fasanella-Servat procedure
Excision of upper border of tarsus, lower border of Muller muscle and overlying conjunctiva
Indicated for mild ptosis with good levator function
..
Fasanella-Servat Mullerectomy
Eyelid inverted Mosqitoes parellel to margin leaving 3-4 mm tarsus exposed Running horizontal matress suture Sliver of muscle & tarsus excised
Levator resection
Shortening of levator complex
Indicated for any ptosis provided levator function is at least 5 mm
Amount determined by levator function and severity of ptosis
After LA and corneal shield-incision taken and suborbicularis plane reachedDissect with needle tip cautery
Normally pulled down 1:1 mm according to deficit but in congenital 1:2 or 1:3 mm pulled 1st suture taken between tarsus and levator aponeurosis Lights deamed Patient asked to look straight and lid position seen Then lid excursion and lagophthalmos checked Slight overcorrection (1-2mm) due to mueller
contraction is done.(however undercorrection is better tolerated by patient)
Excess levator apo. Excised.
Levator Plication
Frontalis brow suspension
Attachment of tarsus to frontalis muscle with sling
• Severe ptosis with poor levator function ( 4 mm or less )• Marcus Gunn jaw-winking syndrome
Requires full range of passive lid movement
Use fascia lata or palmaris tendon or posthetic material
Various desighns available
Incision sites-at lid -3mm above margin—deep till tarsal plate -at brow 3 mm above brow – till periosteum
Plane below orbi. Oculi
Use wright needle
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Most common is asymmetry
under correction ,requires sec.procedures. overcorrection ,requires lubricant , temporary tarsorrhaphy
and if not corrected sec.procdures.
Corneal abrasion or keratitis Entropian or ectropian due to imbalance between anterior
and posterior lamina during repair.
Eyeleshes loss/ocular demage/ extraocular muscle demage/ infection / hematoma.
Wound dehiscence/unfavorable scar/
Complications and management
Thank You