A descriptive and authentic ppt on lid anatomy, ptosis: its clinical evaluation and management taken from Yanoff, Kanski, and Oxford Ophthalmology. videos and photos are included. made from scratch, no slide is copied from any other ppt.

1. ?

3. BLAPHARO-PTOSIS
DR ORANGZEB, Resident F1
Ophthalmology Dept, Liaquat National Hospital Karachi

4. OBJECTIVES
PTOSIS?
1
CLINICAL ANATOMY OF LID
2
CLASSIFICATION
3
4 MENAGEMENT

5. PTOSIS
PSEUDO-PTOSIS
Abnormally low position of the upper lid margin, while the eye in primary gaze
False impression of ptosis
• Lack of support by globe i.e. microphthalmos, phthisis, enophthalmos,
prosthesis
• Contr lid retraction/Proptosis/large globe: it covers about 2mm in adult
• Ipsi hypotropia: disappears on fixation
• Brow ptosis: disappears on manually elevating brow
• Dermatochalasis: may also cause mechanical ptosis

6. CLINICAL ANATOMY OF LID

7. CLINICAL ANATOMY OF LID
 In young interpalpebral fissure height is 10–11 mm. With advancing age = 8–
10 mm.
 In primary position, the upper eyelid margin lies at the superior limbus in
children and 1.5–2 mm below it in adults.
 The lower eyelid margin rests at the inferior limbus.
 The margin is covered by cutaneous epithelium through which the eyelashes
emerge anteriorly; posteriorly it is interrupted by meibomian gland orifices.
 The cutaneous epithelium is continuous with the conjunctival epithelium at
posterior border of the lid margin.

8. Orbicularis oculi
 Sheet of striated muscle just below skin
Divided into 3
1. Orbital
2. Lacrimal
3. Palpebral (pretarsal and preseptal)
Fibers sweep circumferentially around each eyelid as a half ellipse
fixed medially and laterally at the canthal tendons.
Supplied by facial nerve

9.  Preseptal: Infront of orbital septum, its fibers originate perpendicularly along the
upper and lower borders of the medial canthal tendon. Fibers arc around the
eyelids and insert along the lateral horizontal raphe.
 Pretarsal: Overlies the tarsal plates. Originate from the medial canthal tendon via
separate superficial and deep heads, arc around the lids, and insert onto the later
al canthal tendon and raphe.

10. Orbital septum
 Thin fibrous membrane that begins at orbital rim; it is continuation of the orbital
periosteum.
 Distal fibers merge into levator aponeurosis. Inserts usually 3–5 mm above the
tarsal plate can be as high as 10-15 mm
 In the lower lid the septum fuses with the capsule-palpebral fascia several mms
below the tarsus that inserts onto the inferior tarsal edge
 Prevents infections from going to the orbit
 Prevents prolapse of fat out of the orbit

11. Major Eyelid Retractors: Levator palpabrae superioris
 LPS arises from the lesser sphenoid wing and runs above the SR.
 Near the superior orbital rim, a condensation along the muscle sheath, which
attaches medially and laterally to the orbital walls, the ligament of Whitnall
 Fibers passes into its aponeurosis continues downward 14–20 mm, attached at
anterior tarsus 3–4 mm above margin.
 It sends interconnecting slips to insert onto S/C tissue that defines lid crease.
 Supplied by 3rd CN (unpaired and central)

12. Major Eyelid Retractors: Levator palpabrae superioris
 In lower lid, the capsulopalpebral fascia: fibrous sheet that arises from sheaths
around the inferior rectus and inferior oblique muscles.
 Passes upward, fuses with fibers of the orbital septum about 4–5 mm below the
tarsal plate. From this junction, a common fascial sheet continues upward and
inserts onto the lower border of the tarsus.

13. Major Eyelid Retractors: Muller muscle
 Originates from the undersurface of the levator muscle just anterior to Whitnall’s
ligament. Runs downward, posterior to the levator aponeurosis, inserts onto the
anterior edge of the superior tarsal border
 Disruption of the innervation leads to Horner’s syndrome superior cervical ganglion
 Several mm of elevation esp in primary gaze

14. Tarsal plate
 Dense fibrous tissue, provides structural support
 Central height is 8-12 mm in upper and 3.5- 5mm in lower lids
 Meibomian glands are within it
 Gives eyelid its shape/support

15. CLINICAL ANATOMY OF LID

17. Clinical evaluation
History
 Age of onset, duration, severity, variability
 Hx of Trauma/ any ocular surgery
 Diplopia, ocular surface issues
 Aggravating and relieving factors
 Family hx
 Past and current photographs

18. Clinical evaluation
Examination: measurements
 MRD 1: N=4-5 mm
 MRD 2:
 Palpebral fissure height: varies with ethnicity and gender N=8-12 7-10mm
Compare it with other eye
Mild 2mm, moderate 3mm, severe 4mm or more

19. Clinical evaluation
Examination: measurements
 Levator function:
N= 15 or more, Good=12-14, Fair= 5-11, Poor= 4 or less mm
 Upper lid crease: 12mm 8mm
 Pretarsal show: b/w lid margin and skin fold in primary position

21. Clinical evaluation
Examination
 Pupils : miosis and mydriasis
 Eye position/EOMs
 Head position
 Signs of ocular inflammation/ dryness → Reactive ptosis
 Bilateral asymmetrical ptosis: herring's law: assessed by manually elevation
ptotic eye

22. Clinical evaluation
Examination
 Fatigability: up gaze for 1 min , Cogan twitch sign, “hop” on side gaze
 Ocular motility
 Jaw winking
 Bells phenomenon
 Tear film
 Brow elevation

23. Classification
Myopathic ptosis
Blepharophimosis syndrome
Marcus Gunn’s jaw-winking syndrome
Congenital Acquired
Third nerve palsy
Horner’s syndrome
Myasthenia gravis
CPEO
Aponeurotic ptosis
Mechanical ptosis
Myotonic dystrophy

24. Classification
Aetiology
 Neurogenic
 Myogenic
 Aponeurotic/involutional
 Mechanical

28. ?

29. Isolated congenital ptosis
 Unilateral in 69%
 Probably failure of neuronal migration
 Usually remain stable
 Lid crease is absent?
 Poor levator function
 Ptotic lid higher in downgaze?
 Amblyopia (20%) usually due to strabismus (30%) (hypoT) or anisometropia (12%)
 Compensatory chin elevation in B/L ?
Developmental myopathy of LPS

30. Isolated congenital ptosis
 Anterior levator resection if levator function is reasonable
 Brow suspension for poor levator function
Unilateral if associated brow elevation
B/L with ablation of LPS is preferred
SURGERY

32. Blepharophimosis syndrome
 6% of ptosis
 Severe B/L ptosis with poor LF
 Phimosis → Telecanthus
 Hypertelorism
 Epicanthus inversus
 Amenorrhea
 Temporal ectropion
AD

33. Blepharophimosis syndrome
 Telecanthus and epicanthal folds are corrected first
 Then B/L frontalis suspension
SURGERY

34. ?

35. Marcus gun jaw winking ptosis
 Unilateral
 Due to misdirection of ipsilateral mastication muscles 1
 MC to external pterygoid muscle
 Retraction with chewing, sucking, opening mouth or jaw movement
 Severity of ptosis and winking are not proportionate
 LF is decreased with crease
 Hypotropia 2
Non hereditary - 5% of congenital ptosis
1 Lewy FH, Groff RA, Grant FC. Autonomic innervation of the eyelids and the Marcus Gunn phenomenon. Arch Neurol Psychiatry. 1937;37:1289–97
2Oesterle CS, Faulkner WJ, Clay R, et al. Eye bobbing associated with jaw movement. Ophthalmology. 1982;89:63–7.

36. Marcus gun jaw winking ptosis
 Doesn’t improve with age
 Mild = Anterior levator resection
 Severe = Ablation/Disinsertion of LPS ě brow suspension 1
 B/L surgery is preferred
Surgery
1 Bowyer JD, Sullivan TJ. Management of Marcus Gunn jaw winking synkinesis. Ophthalmic Plast Reconstr Surg. 2004;20:92–8.

37. VIDEO

38. ?

39. 3rd CN palsy
 Intranuclear lesion→ B/L symmetrical
 Peripheral (MC) due to trauma, neoplasm, ischemia or aneurysm
 Decreased/ absent LF
 Mydriasis?
 Strabismus ?
 Aberrant regeneration → bizarre movement with eye movements

40. 3rd CN palsy
Sequalae/ Surgery
 Spontaneous recovery
 Surgery is delayed 6-12 months 1
 Brow suspension with levator disinsertion?
 Strabismus is corrected first otherwise → intractable diplopia??
1 Krohel GB. Blepharoptosis after traumatic third-nerve palsies. Am J Ophthalmol. 1979;88:598–601.

41. ?

42. Horner’s syndrome
Congenital and acquired
 Sympathetic denervation
 Ptosis (partial ě preserved LF) Miosis + Anhidrosis
 Elevation of lower lid → ↓ palpebral fissure
 Heterochromia with congenital Horner’s 1
1 Weinstein JM, Zweifel TJ, Thompson HS. Congenital Horner’s syndrome. Arch Ophthalmol. 1980;98:1074–8.

43. Horner’s syndrome
Pharmacological tests
 To diagnose Horner’s
• Cocaine test: 4/10% +ve = Anisocoria of at least 1mm
• Apraclonidine test: 0.5/1% +ve = Dilation of Horner’s pupil (avoid in
children)
 To localize the lesion pre vs post-ganglionic
• Hydroxy amphetamine test 1% +ve =peripheral Horner’s
 Medical evaluation is necessary in newly diagnosed cases

44. Horner’s syndrome
Surgery
 Persistent
 External levator resection
 Mullerectomy without tarsal resection

45. Tensilon ?

46. Myasthenia gravis
Auto immune disease of NMJ
 Eye involvement 96% 1
 Ptosis and diplopia p/c in 86% of the pts 1
 Variable and fatigable ptosis
 Unilateral, bilateral or alternating
 Worse at the end of day
 Minority has just ocular disease
 Associated ě thymoma and para-neoplastic syndromes
1 Mattis RD. Ocular manifestations in myasthenia gravis. Arch Ophthalmol. 1941;26:969–82.

47. Myasthenia gravis
Evaluation
 Single fibre EMG
 Fatigability test (twich /failure to maintain)
 Cogan twitch sign “hop” on side gaze
 Ice pack test
 Tensilon test
 CXR for ?
 Ach R abs
 Anti MUSK ab

48. Myasthenia gravis
VIDEO

49. Myasthenia gravis
Management
 Medical
 Thymectomy
 Limited frontalis suspension in refractory/debilitating ptosis
 Risk of exposure is high but why?
 Fluoroquinolones and aminoglycoside should be avoided

50. CPEO

51. CPEO
Heredity or sporadic
 Mitochondrial myopathy
 B/L usually symmetrical
 Restricted EOMs without diplopia
 EOMs are involved later
 Chin lift
 Kearns-Sayre syndrome (conduction defect)
 Oculopharyngeal dystrophy (dysphagia)

52. CPEO
Management
 Dx: Muscle biopsy
 Limited frontalis suspension
 Delayed until very significant as risk of exposure?
 Brow function is reduced over time
 Spectacles/ scleral CL-mounted props/crutches

53. CPEO
Management

54. ?

55. Aponeurotic
Involutional / Senile
 Slowly progressive B/L ptosis
 Ptosis worse at end of day with no fatigability
 High/absent crease
 Lid above tarsus becomes thin
 Good LF

56. Aponeurotic
Involutional
 Dehiscence/ Disinsertion/ stretching of Levator aponeurosis
Due to
1. Trauma
2. Any ocular surgery (speculum use) 6% of cataract surgery 1
3. Excessive rubbing
4. Periorbital steroids
5. Chronic CL use
1 Feibel RM,et al. Postcataract ptosis – a randomized, double-masked comparison of peribulbar and retrobulbar anesthesia. Ophthalmology.1993;100:660-5.

58. Aponeurotic
Surgery
 Levator resection
 Advancement
 Repair
 Reinsertion

60. Machanical
 Dermatochalasis
 Tumour (NF)
 Chalazion
 Scar
 Oedema
 Anterior orbital lesions

61. Treatment
Surgery
 Surgery should be avoided in those ě ocular irritation/photophobia
 Differed unless occlusive amblyopia till 3-5 yrs.
 Dryness increase after elevation
 ↓ LA with minimal lid injection
 ↓ GA in children/ fascia lata harvest.
PRE-OP

62. Treatment
Surgery
 Amount and type of ptosis
 LF
 The skin incision is placed in the location of the desired crease.
 Contralateral crease is matched in unilateral ptosis
 Creases are absent/indistinct in B/L disease
 Incisions at 1/3rd distance lashes to the lower edge of the brow.

63. Levator advancement
Aponeurotic advancement/ resection
 LF of at least 5mm
 Preferred in moderate-good LF
 Levator complex is shortened
 Through anterior or posterior approach( predictability of correction is same but
lid contour with post: is more predictable )
 In severe cases maximum resection can be done but postop lagophthalmos is
common

64. Levator advancement
Technique
 Measurements in upright and recumbent
 Skin incision → oculi is divided → septum is divided → preaponeurotic fat is
retracted to expose the muscle
 Levator aponeurosis may be thin or completely dehisced
Remaining attachments of the aponeurosis are divided, exposing the tarsus →
Aponeurosis is separated from underlying Müller muscle with blunt and sharp
dissection

65. Levator advancement
Technique
 In severe congenital ptosis, the combined aponeurosis-Müller muscle complex
can be advanced
 The awake is asked to look in primary gaze, allowing the surgeon to determine
whether it has altered preop lid level
 The lid is adjusted empirically in patients ↓GA, considering preop LF and
amount of ptosis.

66. Levator advancement
Technique
 2 partial thickness 6-0 polyester sutures are placed in central third of the tarsus
 Redundant aponeurotic tissue is excised.
 Crease is reformed by suturing the cut edge of the pretarsal orbicularis muscle/
S/C tissue to the aponeurosis ě 7-0 polyglactin
 The skin is closed with a running 7-0 polypropylene

68. Levator advancement
Post op
 Cold compresses: 48 hours to minimize edema and ecchymosis. Wet and warm
compresses : wound hygiene.
 Ointment on wound several times
 ROS 5–7th POD
 There may be transient lagophthalmos and poor blink post-op attributable to
orbicularis under action that improves weeks post-op

70. Brow/frontalis suspension
 Severe ptosis >4mm
 Very poor LF <4mm
 Intact frontalis function
 3rd CN palsy, BP syndrome,
 With previous unsuccessful L-resection
 Sling of autologous fascia lata / silicone/ prolene
 <3yrs = difficult to obtain sufficient facia lata

71. Brow/frontalis suspension
Harvesting facia lata
 3-cm incision is made on the lower thigh, just above the lateral condyle.
 The white, glistening fascia lata is visible underneath S/C fat.
 Blunt dissection is performed on the anterior surface of the fascia, upto lateral
aspect of the leg for about 15–20 cm.
 A strip of fascia 6–8 mm wide and 15–20 cm long is harvested using a fascial
stripper and cutter, cleaned and divided into strips 2–3 mm wide.

72. Brow/frontalis suspension
Technique
 Incision location and pattern of the implanted material are determined by brow
contour 1
 Pentagonal sling = diffuse brow elevation
 Medial and lateral incisions at the superior border of the brow at limbus.
 A central forehead incision 10 mm above
 Triangular slings are more ideal in individuals with segmental brow elevation,
utilizes a single incision above portion of brow exhibiting max movement
 Brow incisions are created through skin and S/C tissue, exposing the frontalis
 Crease incision is used to expose tarsus
1 Ben Simon GJ, Macedo AA, Schwarcz RM, et al. Frontalis suspension for upper eyelid ptosis: evaluation of different surgical designs and suture material. Am J Ophthalmol. 2005
;140:877–85.

73. Brow/frontalis suspension
Technique
 Implant is sutured to the upper anterior surface of the central tarsus with several
partial-thickness 6-0 polyester sutures
• Eyelid contour is adjusted by altering the width of this attachment.
 A Wright fascial needle is used to pass sling, 1st through the peripheral then
central brow incision.
 Passed deep to orbital septum and superficial to the periosteum of the orbital rim

74. Brow/frontalis suspension
Technique
 Crease is recreated and closed prior to adjustment
 Adjusted to achieve the height and contour, joined with permanent sutures
(fascia) / silicone sleeve (silicone rods) buried
 The brow and leg incisions are closed in a layer.

75. Brow/frontalis suspension
Technique

76. Brow/frontalis suspension
Technique

79. Mullerectomy
Conj-muller resection
 Mild ptosis with good LF
 Adequate elevation (topical phenylephrine) 1 2 3
 Excision of Muller muscle and conj with re- attachment
 4mm resection → 1 mm correction (height assesd pre-op)
 Max elevation of 2-3
 Horner’s and mild congenital ptosis
1 Putterman AM. Muller muscle-conjunctiva resection technique for treatment of blepharoptosis. Arch Ophthalmol. 1975;93:619–23.
2 Weinstein GS, Buerger GF. Modifications of the Muller’s muscle-conjunctival resection operation for blepharoptosis. Am J Ophthalmol. 1982;93:647–51.
3. Ben Simon GJ, Lee S, Schwarcz RM, et al. External levator advancement vs Muller’s muscle-conjunctival resection for correction of upper eyelid involutional ptosis. Am J Ophthalmol. 2005;140:42

80. Mullerectomy
Conj-muller resection
 3 traction sutures are placed using silk
 Sutures are placed first then resection (U uninterrupted)
Full thickness at start and end
Posterior resection of muller muscle is preferred in pts showing adequate elevation
following phenylephrine instillation

81. Mullerectomy
Conj-muller resection

83. Complications
 Excessive dissection of the levator may traumatize the SO/ lacrimal gland ductules
 Appropriate preop evaluation and patient selection reduce the risks of postop
ocular irritation, keratitis, and photophobia.

84. Complications
Under correction MC
 10–15%
 Should be observed until edema and lid position has stabilized
 Some pts require further evaluation bcz an unsuspected acquired myopathy may
be responsible for recurrent or poorly corrected ptosis.
 Surgical revision is considered in patients with persistent symptomatic ptosis.

85. Complications
Overcorrection
 Mild overcorrection following surgery should be observed until lid position has
stabilized
 Digital massage or “squeezing” occasionally lower the eyelid
 Surgical revision with recession of the levator or suspension material is indicated
in cases with persistent overcorrection.
 Early intervention: pts with marked postop overcorrection and ocular exposure 1
1 Park DH, Jung JM, Choi WS, Song CH. Early postoperative adjustment of blepharoptosis. Ann Plast Surg. 2006;57:376–80.

86. Complications
Eyelid Crease Abnormalities
 Incorrect incision or failure to create crease→ indistinct or poorly positioned crease.
 Absent/ abnormally low crease may be reformed by placing an incision through skin
and orbicularis muscle at the location of the new crease.
The S/C tissue is sutured to the aponeurosis prior to skin closure.

87. Complications
Eyelid Crease Abnormalities
 Difficult to lower abnormally high crease.
Attachment b/w skin-orbicularis muscle and the aponeurosis must be separated.
Soft tissue, such as orbital fat, should then be mobilized between these layers in an
effort to minimize the establishment of a new adhesion in same location.
 The new crease is then established at a lower level.

88. Complications
Lagophthalmos and Exposure Keratitis
 Keratitis due to
 Punctual occlusion in severe (lubricants for mild)
 Persistent keratitis : lowering of the upper lid
 Elevating the lower lid, canthoplasty, and tarsorrhaphy :reversal would be debilitating

89. Complications
Changes in Astigmatism
 Changes in corneal astigmatism = 72% 1
 With-the-rule, regress to preop level within 1 year
1 :Holck DE, Dutton JJ, Wehrly SR. Changes in astigmatism after ptosis surgery measured by corneal topography. Ophthalmic Plast Reconstr Surg. 199
8;14:151–8.

90. Complications
Prolapse of the Superior Conjunctival Fornix
 Excessive advancement of the aponeurosis or Müller’s muscle may cause prolapse
of superior conj.
 This results from failure to separate the fine attachments between the aponeurosis
and the superior fornix suspensory ligaments
 If the conj is easily reduced, pressure patch for several days
 Once fibrotic, direct excision is necessary.

94. Thank you
PATIENTS ARE WAITING