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