303A.J. Cohen and D.A. Weinberg (eds.), Evaluation and Management of Blepharoptosis, DOI 10.1007/978-0-387-92855-5, © Springer Science+Business Media, LLC 2011

AAcetylcholine receptor antibodies (AChR), 47Acquired myogenic ptosis. See Myogenic ptosisAesthetic considerations, ptosis surgeon

Arnica montana, 251blepharoptosis, 249dermatochalasis, 250intraoperative IV dexamethasone, 251levator advancement technique, 249MMCR and FS procedure, 249ptosis procedure, 249vitamin E ointment, 251

Amblyopia, 292Ambulatory surgical center (ASC), 233Anesthesia

injectable anesthetics, 238–239topical anesthetics, 237–238

Anophthalmic ptosisetiology

anophthalmic socket, 141, 142forniceal shortening, 143iatrogenic injury, 143levator mechanism, 143levator-superior rectus complex,

142–143evaluation, 143–144surgical techniques, 144

Anti-muscle-specific kinase (anti-MuSK), 110Aponeurotic ptosis, 8.

See also Involutional ptosisAporneurotic repair, 256Apraclonidine, 158–159Apraxia of eyelid opening (AEO), 116Aquaphor, 251Arnica montana, 251

BBell’s palsy

acquired myogenic ptosis, 95congenital myogenic ptosis, 79

involutional ptosis, 74patient selection, 156prior ocular and periocular surgery, 32

Benign essential blepharospasm (BEB)apraxia, 254dystonic eyelid closure, 254etiology and evaluation, 253–255surgery

aponeurotic ptosis repair, 256complications, 256–257frontalis sling, 256

treatment, 255–256Birth trauma, 132, 133Blunt trauma, 133Botulinum toxin, 160, 253, 255

acquired myogenic ptosis, 100, 101nonsurgical treatment, 160pseudoptosis, 63, 64risk factor assessment, 34

CChronic progressive external ophthalmoplegia

(CPEO), 94, 108, 156Clonidine, 235Clopidogrel, 31Coloboma repair, 292Congenital ptosis, 35

aponeurotic causes, 68clinical examination, 69dystrophic, 47frontalis suspension, 71levator resection, 70–71management strategy, 71mechanical causes, 68Müllerectomy, 70myogenic causes, 67myogenic ptosis, 67

blepharophimosis syndrome, 93fibrosis syndrome, 93frontalis suspension, 265

Index

304 Index

levator function, 93, 94levator resection, 265–267maximal levator resection, 267Whitnall’s Sling, 267

neurogenic causes, 68preoperative considerations, 69–70, 72pseudoptosis, 68–69surgical repair, 70

Conjunctival prolapse, 285, 286Conjunctival-tarsal-Müllerectomy (insert sym).

See Fasanella-Servat procedureContinuous positive airway pressure

(CPAP), 34Contour deformity

anterior or posterior tarsectomy, 283floppy tarsal plates, 282–283frontalis suspension, 284improper suture placement, 282, 283posterior lamellar approach, 283–284

Contralateral eyelid drooping, 271Cranial nerve III palsy, 68Cutler-Beard flap, 260

DDermatochalasis, 61, 62, 270Desmarres retractor, 181, 198–199Dry eye syndrome, 29

EEcchymosis, 270–271Ectropion, 259, 260

frontalis contraction, 282poor function bilateral ptosis, 281, 282treatment, 281–282

Edrophonium test, 109–110Electromyography (EMG), 99En bloc technique, 211–213Entropion

anterior lamellar repositioning, 278, 280keratopathy and corneal ulceration, 278suture placement, 278–280

Epicanthoplasty, 247Epinephrine, 164Ethnic and gender considerations, ptosis surgery

African-American patients, 245anatomical factor, 245Asian patients, 243, 245epicanthal folds, 247epicanthoplasty, 247eyelid

anatomy, 247crease, 243–244surgery, 244

eyelid-eyebrow relationship, 2

subcutaneous epicanthoplast, 247Expanded polytetrafluoroethylene

(ePTFE), 222Extensor digitorum longus (EDL), 24External levator resection, 255, 265–267

phenylephrine test, 163procedure

anesthesia, 164–165antibiotic ointment, 170aponeurosis, 170basic instrument set, 163, 164A #15c blade, 165CO2 laser, 165, 166congenital ptosis, 171double-armed 5-0 polypropylene, 168epinephrine, 165hyaluronidase, 165levator aponeurosis, 170lid crease, 163–164Müller’s muscle, 164polypropylene suture, 171tarsal plate, 167tarsectomy, 172Whitnall’s ligament, 168–169

Eyelidscrease, 291laxity, 259, 270, 271lower eyelid (see Lower eyelid)motor nerves, 21sensory nerves, 22upper eyelid (see Upper eyelid)vascular supply, 21–22

FFacial fractures, 133, 135, 136Facial nerve palsy (FNP), 40Fasanella-Servat procedure, 259, 260

complications, 201, 203–204contour abnormalities, 204history, 7, 8, 197indications, 198mechanism of action, 197–198Müller’s muscle, 202oculoplastic surgery, 204postoperative dermatochalasis, 203procedure

advantage, 204Desmarres retractor, upper eyelid position,

198–199double-armed absorbable suture, 199–201patient positioning, 198Putterman clamp placement and removal,

199–201suture testing, 202–203

305Index

tarsus and reflected conjunctiva resection, 201, 202

tarsus grasping, 199surgical outcomes, 204

Floppy eyelid syndrome (FES), 34, 147, 259Fox technique, 225Frontalis sling surgery, 255–256Frontalis suspension technique, 6, 265, 269

allografts, 220autogenous fascia lata, 217–228double triangle or rhomboid frontalis sling,

223–224indications, 217muscle flap advancement, 220palmaris longus tendon, 219–221single pentagonal frontalis sling

Crawford technique, 224Fox technique, 224, 225ophthalmic ointment, 224

synthetic materialsexpanded polytetrafluoroethylene

(ePTFE), 221monofilament nylon and polypropylene, 221polyester fiber, 222polyfilament cable-type suture, 221–222

temporalis fascia, 218–219Full-thickness eyelid resection

chalazion clamp, 212definition, 207en bloc technique, 211–213eyelid reconstruction, 212indications, 208lamellar technique, 210MCD/MFD, 209multioperated eyelids, 207normal upper eyelid, 208pearls, 214ptotic and nonptotic eyelid, 211segmental ptosis, 211–212, 214

GGiant papillary conjunctivitis (GPC),

33, 132

HHang-dog expression, 96Hematomas, 285–286Hemifacial spasm (HFS)

etiology and evaluation, 253–255pseudoptosis, 62–63surgery

aporneurotic ptosis repair, 256complications, 256–257frontalis sling, 256

treatment, 255–256unilateral eyelid closure, 254

Hering’s law, 52, 163, 201, 270, 271Homovanillic acid (HVA), 127Horner syndrome, 68, 132, 189

children, 126–127diagnosis

classic findings, 121, 122clinical signs, 122

localizationetiology, 124, 125oculosympathetic pathway, 123, 124thyroidectomy, 125

pharmacologic evaluation, 122–123radiographic evaluation, 125–126treatment, 127

Hughes procedure, 167Hypotropia, 63–64

IInformed consent

evidence, complicated surgery, 293planned surgical procedure, 292–293surgeon review, 293–294

Injectable anesthetics, 238–239Involutional ptosisanatomic and histopathological changes,

75–76blepharoptosis, 73clinical findings, 74etiology, 73–74levator advancement/plication, 263–264levator aponeurosis, 73Müller muscle conjunctival resection, 264ophthalmic examination

Müller’s muscle-conjunctival resection, 75, 76

myasthenia gravis, 74phenylephrine, 75

preoperative evaluation, 77treatment, 76–77

KKeratitis sicca, 291Keratorefractive surgery, 301

LLagophthalmos, 267, 271, 284Lambert-Eaton myasthenic syndrome (LEMS), 100Lamellar technique, 210Lash ptosis (LP)

clinical evaluation, 148etiology, 150minimal, 150

306 Index

moderate to severe, 150pathophysiology, 147–149rating scale, 147, 148severity, 151surgical management, 148

Layer-by-layer dissection, 214Levator advancement, 263–264Levator aponeurosis, 269, 272–273Lower eyelid

capsulopalpebral fascia, 19orbicularis muscle, 15orbital septum, 16precapsulopalpebral fat pockets, 17sensory nerves, 22sympathetic eyelid retractors, 20tarsal plates, 20vascular supply, 23

MMarcus-Gunn jaw-winking syndrome, 68, 217Marginal reflex distance (MRD), 3, 51, 179, 270, 271Margin-to-crease distance (MCD), 209Margin-to-fold distance (MFD), 209Mechanical heart valve, 291Meibomian gland orifices, 13–14Methyliodobenzyguanadine (MIBG), 127Minimal-dissection ptosis correction, 175, 178Modified Motais operation, 7Monitored anesthesia care (MAC), 180Müller muscle conjunctival resection (MMCR).

See also Open-sky müller muscle resection

eyelid elevation, 179involutional ptosis, 75, 76vs. levator aponeurosis surgery, 264linear regression algorithm, 180phenylephrine, 179–180preoperative decision making, 52–54reoperation rate, 269technique

advantages of, 186frontal or supraorbital nerve block,

180–181glaucoma filtering blebs, 185Putterman clamp, 183

Müller’s muscle, 164, 176, 177Muscle-specific kinase (MUSK), 47Myasthenia gravis (MG), 38

acetylcholine receptor (AChR), 107clinical diagnosis

compensatory brow elevation, 108congenital phoria, 108dysthyroid orbitopathy, 108physical finding, 109

quantitative measurement, 108–109rest test, 109

clinical testinganti-AChR antibodies, 110anti-striated muscle, 110computed tomography, 111edrophonium test, 109–110electromyographic (EMG) testing, 110–111pyridostigmine test, 110

medical therapyazathioprine, 112cyclophosphamide, 112cyclosporine A, 112mycophenolate mofetil, 112prednisone therapy, 111pyridostigmine therapy, 111steroid treatment, 111–112tacrolimus, 112

ocular symptoms, 107–108surgical therapy, 112–113

Myectomy, 255, 256Myogenic ptosis

acquiredacetylcholine receptor, 98–99antiretroviral therapy, 101, 102bilateral severe ptosis, 96, 97botulinum toxin, 100, 101chin-up head position, 96, 99CPEO, 94, 95frontalis slings, 97, 98frontalis suspension, 94, 95levator muscle damage, 100, 101myasthenia gravis, 97, 99myotonic dystrophy, 96oculopharyngeal muscular dystrophy, 97, 98orbital radiotherapy, 101, 102para neoplastic syndrome, 100ragged red fiber, 95

conditions, causes, clinical features, 79–92congenital

blepharophimosis syndrome, 93fibrosis syndrome, 93levator function, 93, 94

patient evaluationdiagnostic evaluation, 102–103margin-reflex distance, 102physical examination, 101retinopathy, 103

treatmentclinical manifestations, 105complications, 104Crawford frontalis sling procedure, 104–105lagophthalmos, 103progression, 105

307Index

unilateral ptosis surgery, 104

NNerve palsy, 38. See also Third nerve palsyNeurofibromatosis, 260–262Neurogenic blepharoptosis

cortical and supranuclear, 115–116Horner syndrome

children, 126–127diagnosis, 121–122localization, 123–125pharmacologic evaluation, 122–123radiographic evaluation, 125–126treatment, 127

supranuclear inhibition, 115third nerve palsy

diagnosis, 116–118etiology, 120localization, 118–120treatment, 120–121

OOcular cicatricial pemphigoid, 292Ocular surface disease

allergic eye symptoms, 30corneal staining patterns, 29dry eye syndrome, 29schirmer test, 30

Oculopharyngeal muscular dystrophy (OPMD), 96Office based surgery

anxietymedical prevention, 235–236nonmedical prevention, 235patients risk evaluation, 234surgery protocol, 240–241

ophthalmology, 231patient selection, 233–234Postoperative nausea and vomiting (PONV),

236–237postoperative pain control, 239–240procedure selection, 233reasons to transition, 231state regulations, 232–233surgical space and equipment,

231–232Open-sky Müller muscle resection

bilateral ptosis, 193congenital ptosis, 194conjunctiva, preservation, 190–191Horner’s syndrome, 189levator aponeurosis., 190, 191lid margin rising, 192–193phenylephrine test, 191–192Putterman clamp vs. closed technique, 193

surgical technique, 190unilateral ptosis, 194

Open-sky technique, 193Orbicularis muscle spasm, 254Orbicularis oculi muscle, 176, 177Orbital biopsy, 116, 117Over and under correction, ptosis repair

congenital or acquired ptosis, 276–277frontalis suspension, 276intraoperative variables, 276myasthenia gravis and bilateral ptosis, 277, 278posterior approach ptosis repairs, 276posterior lamellar approach, 277–279postoperative swelling, 276unilateral procedure, 277

PPhenylephrine, 191–192PolyA-binding protein 1 (PAPBN1), 97Polytetrafluoroethylene (PTFE), 265Postenucleation socket syndrome, 141, 142Postoperative nausea and vomiting (PONV),

236–237Preoperative decision making, ptosis surgery

anticoagulant medication, 54–55intraoperative bleeding, 55myasthenia gravis, 56patient expectations, 55–56patient history, 49–50physical examination

corneal sensation, 51eyelid laxity and eversion, 51Hering’s dependency, 52ice and rest testing, 52, 53levator function, 51, 52margin-reflex distance, 51ocular motility, 50slit lamp examination, 51

procedure determinationacquired and congenital ptosis, 52–53etiology, 52external levator resection, 53frontalis sling procedure, 54full-thickness horizontal eyelid resection, 54mild ptosis, 53, 54Müller’s muscle-conjunctival resection,

53–54unilateral or bilateral procedure, 54

Prior ocular and periocular surgeryanesthetic toxicity, 31anophthalmic sockets, 32–33corneal topography, 33glaucoma, 32lagophthalmos and exposure keratopathy, 32

308 Index

monocular diplopia, 32refractive error, 33

Progressive supranuclear palsy (PSP), 116

Pseudoptosisbotulinum toxin, 63, 64dermatochalasis, 61, 62enophthalmos, 64eyelid retraction, 62, 63hemifacial spasm, 62–63hyperglobus, 65hypotropic eye, 63–64ocular misalignment, 64strabismus, 63upper eyelid creases, 61, 62volume deficiency, 64–65

Ptosis. See also Safe ptosis; Unsafe ptosisclassification

blood test, 47radiology, 48tensilon test, 47

definition, 3management, 3–4margin reflex distance, 3–4nonsurgical treatment

apraclonidine, 158–159botulinum toxin, 160epinephrine, dipivefrin, 159–160eyelid taping, 158glue, 158interim therapy, 155lid crutch, 157mechanical lifting, 155patient selection, 155–157phenylephrine, 159–160

subclinical contralateral ptosisdry eye patient, 46frontalis overaction, 45–46lid lifting, 44lid retraction, 44–45proptosis and enophthalmos, 45, 46

sympathomimetic effect, 37Ptosis surgery. See also Aesthetic considerations,

ptosis surgeonchronology, 5complications

conjunctival prolapse, 285, 286contour deformity (see Contour deformity)corneal abrasion, 287ectropion, 281–282entropion, 278–280eyelid fold and crease, 284–285hematomas, 285–286infection, 286–287

lagophthalmos, 284over and under correction (see Over and under

correction, ptosis repair)ethnic and gender considerations (see Ethnic and

gender considerations, ptosis surgery)failure

external approach, 269eyelid height and contour, 269–270intraoperative factors, 270–272postoperative factors, 272preoperative factors, 270

history, 5–8preoperative decision making (see Preoperative

decision making, ptosis surgery)reoperation

lagophthalmos, 273minimal overcorrection with

eyelid massage, 273minimal scarring, 272–273postoperative abnormalities, 273residual ptosis, 273

risk factor assessmentanticoagulants, 30blepharospasm, 34botulinum toxin use, 34congenital ptosis, 35contact lens, 33–34continuous positive airway pressure, 34diplopia, 34floppy eyelid syndrome, 34hygiene assessment, 35medial canthal webbing, 35ocular surface disease

(see Ocular surface disease)physical examination, 29prior ocular and periocular surgery, 31–33prostaglandin analog, 31smoking, 35strabismus, 34

scarpa’s procedure, 6Pyridostigmine therapy, 111

RRelative afferent pupillary defect (RAPD), 50Rheumatoid arthritis, 291Rigid gas permeable (RGP) lenses, 33–34Risk management

patient-physician relationship, 290surgeon experience, 289surgical encounter

anatomic, medical, psychological, and social factors, 291–292

complications management, 298–299diagnosis, 290–291

309Index

final outcome assessment, 299informed consent process, 292–294office revisit and follow-up, 299–300patient concern, normal healing, 296–297patient expectations, surgery, 294–295patient/procedure selection, 292, 293surgical outcomes identification, 297–298surgical planning, 295, 296technical execution, 295–296

SSingle fibre electromyography (SFEMG), 48Small incision ptosis correction

anesthesia, 175–176aponeurosis, 177–178incision planning, 175Müller’s muscle, 176, 177orbicularis oculi muscle, 176, 177sharp stitch-ribbon scissor, 176tarsal plate, 176

Superior orbital fissure syndrome (SOFS), 137Symblepharon, 279–280Synkinetic ptosis, 68, 139

TTarsal insufficiency, 259–260Tarsal switch, 257–258Tarsoconjunctival resection, 264Tensilon test, 109Third nerve palsy

diagnosisaberrant regeneration, 118profound blepharoptosis,

116, 117etiology, 120localization

anatomic pathway, 118, 119Benedikt syndrome, 119cavernous sinus, 119, 120

treatment, 120–121Thyroid eye disease, 23Toxin-mediated paresis, 160Traumatic blepharoptosis

birth trauma, 132, 133blunt trauma, 133

contact lens wear, 131–132facial fractures, 133, 135, 136Horner syndrome, 132management

laceration, 138müllerectomy, 138synkinetic ptosis, 139third nerve palsy, 138–139

posteyelid and adnexal procedures, 130–131postintraocular surgery, 129–130restrictive scarring, 133superior orbital fissure syndrome (SOFS), 137third nerve palsy

facial nerve palsy, 138head trauma, 137–138isolated neurogenic ptosis, 138

traumatic lacerations, 133, 134

UUnder correction, ptosis repair. See Over and under

correction, ptosis repairUpper eyelid

canthal tendon, 20–21conjunctiva, 21levator muscle

aponeurosis, 18–19congenital ptosis, 17conjoint fascial sheath, 17MRI studies, 18orbital fascial systems, 18–19

orbicularis muscle, 15–16orbital septum, 16–17physiology, 23–25preaponeurotic fat pockets, 17skin, 14–15sympathetic eyelid retractors, 19–20tarsal plates, 20

VVanillylmandelic acid (VMA), 127

WWarfarin, 31Whitnall’s sling technique,

262, 267