managemwnt of ptosis.pptx

1. Dr Mubashir Hassan Post graduate resident Orthopedic Surgery Sheikh Zayed Hospital Rahim Yar Khaan

2. Ptosis (Blepharoptosis)

3. Definition Ptosis ( in greek means to fall) is the abnormal drooping of the upper eyelid. Normally upper lid covers about upper one sixth of the cornea i.e about 2mm. Therefore in ptosis it covers more than 2 mm.

9. Evaluation • History taking • Physical Exam • Additional Considerations • Ancillary Tests

10. 5 clinical measurement • Margin-reflex distance • Vertical palpebral fissure height • Upper eyelid crease position • Levator Funtion (upper lid excursion) • Presence of lagophthalmos

12. Margin-reflex distance • 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

13. Vertical Palpebral Fissure • Widest point between the lower eyelid and the upper eyelid • Patient is fixing on a distant object in primary gaze

14. Upper Eyelid Crease Position • Distance from the upper eyelid crease to eyelid margin is measured • Insertion of fibers from the levator muscle into the skinupper 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

16. Levator Function • Upper eyelid excursion from downgaze to upgaze with frontalis muscle function negated

17. Lagophthalmos • Note the gap between the eyelids in mm • Record the tear film quantity and quality

18. Ancillary Test • Visual field 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

19. PTOSIS BY COURSE Traumatic Mechanical Myogenic Aponeurotic Neurogenic BY ONSET CONGENITAL Acquired Classification

21. Aponeurotic ptosis • Acquired aponeurotic ptosis is the most common form of ptosis • Stretching 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

23. characteristic • High or absent upper eyelid crease secondary to upward displacement or loss of the insertion of the levator fibers 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

25. MECHANICAL PTOSIS • Refers to 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…….

26. TREATMENT

27. TREATMENT 1. Levator aponeurosis repair 2. Levator resection 3. Muller’s muscle shortening 4. Brow suspension

28. Key factor • The amount 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.

29. Consideration Procedure of choice LF>4mm Levator resection LF>10mm, ptosis<2mm, response to phrenylnephrine stimulation Muller’s muscle shortening LF<4mm Brow suspension

30. 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

31. Anterior Levator Aponeurosis repair

36. Levator resection • Remember that 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

43. 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

44. Type of response suggestion 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

46. Muller’s muscle and conjunctiva shortening without tarsal plate excision (Open Technique)

48. Frontalis/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,Alloderm and Frozen dura matter may be used

52. alternative

55. Medical therapy Patients with myasthenia gravis may improve with medical treatment. Sympathomimetic topical eye drops such as apraclonidine and phenylephrine provide short temporary lift of the upper eyelid in some patients. Use of topical oxymetazoline hydrochloride (0.1%) for blepharoptosis received FDA approval in July 2020

56. TAKE HOME MESAGE

57. 5 clinical measurement

58. PTOSIS BY COURSE Traumatic Mechanical Myogenic Aponeurotic Neurogenic BY ONSET CONGENITAL Acquired Classification

59. Which operation is prefered? • Degree of ptosis is important • Levator function is also important

60. Ptosis Mild Phrenylnephrine test = positive mullerectomy Phrenylnephrine test = negative Fossanella blepharoplasty Levator resection moderate Levator resection Levator advancement severe Frontalis sling

61. THANK YOU

managemwnt of ptosis.pptx

managemwnt of ptosis.pptx

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managemwnt of ptosis.pptx