Evaluation and Management of Blepharoptosis (eBook)

Dr. Adam J. Cohen, MD, is Consulting Surgeon for Eyelid and Facial Aesthetic and Reconstructive Surgery, Craniofacial Surgery, and Neuro-ophthalmology at Evanston Northwestern Hospital in Evanston, Illinois. He is also in private practice and co-edited the Springer book entitled “The Lacrimal System: Diagnosis, Management, and Surgery" (2006) with Michael Mercandetti and Brian G. Brazzo.

Foreword 8
Preface 10
Acknowledgments 12
Contents 14
Contributors 18
Part I:Introduction 22
Chapter 1: Introduction 23
References 24
Chapter 2: The History of Ptosis Surgery 25
References 29
Chapter 3: Eyelid Anatomy and Physiology with Reference to Blepharoptosis 32
Introduction 32
Eyelid Anatomy 32
Eyelid Skin 33
The Orbicularis Muscle 34
The Orbital Septum 35
The Preaponeurotic Fat Pockets 36
The Major Eyelid Retractors 36
The Levator Muscle and Aponeurosis 36
The Sympathetic Eyelid Retractors 38
The Tarsal Plates 39
The Canthal Tendons 39
The Conjunctiva 40
Nerves to the Eyelids 40
Vascular Supply to the Eyelids 41
Upper Eyelid Physiology 42
References 44
Part II:Approach to the Ptosis Patient 46
Chapter 4: Risk Factor Assessment Prior to Ptosis Surgery 47
Introduction 47
Ocular Surface Disease 47
Medications 48
Prior Ocular and Periocular Surgery 49
Contact Lens Use 51
Miscellaneous Conditions 52
Congenital Ptosis 53
Conclusion 53
References 54
Chapter 5: Ptosis: Nailing the Diagnosis and Considering the Differential Diagnosis 55
Recognise the Ptosis! 55
Diagnose the Aetiology of the Ptosis! 56
Unsafe Ptosis 56
Safe Ptosis 58
Distinguishing Safe Ptosis from Unsafe Ptosis 59
Techniques in Clinical Diagnosisof the Ptosis! 61
Unmasking SubclinicalContralateral Ptosis 62
Lifting the Ptotic Lid 62
Contralateral Lid Retraction 62
Proptosis and Enophthalmos 63
Frontalis Overaction 63
The Dry Eye Patient 63
Classification of Ptosis: The Keyto Aetiology!! 64
Definitive Examination of the Ptosis 65
Special Diagnostic Tests for Ptosis 65
References 66
Chapter 6: Preoperative Decision Making in Ptosis Surgery 67
Introduction 67
History 67
Physical Exam 68
Determination of Procedure 70
Blood Thinners 72
Patient Expectations 73
When Not to Operate 74
References 74
Part III:Ptosis Subtypes 76
Chapter 7: Pseudoptosis 77
References 81
Chapter 8: Congenital Ptosis 82
Pathogenesis 82
Myogenic Causes 82
Aponeurotic Causes 83
Mechanical Causes 83
Neurogenic Causes 83
Pseudoptosis 83
Examination 84
Preoperative Considerations 84
Surgical Repair 85
Müllerectomy 85
Levator Resection 85
Frontalis Suspension 86
Conclusions 86
References 87
Chapter 9: Involutional Ptosis 88
Introduction 88
Background 88
Etiology 88
Clinical Findings 89
Ophthalmic Exam 89
Anatomic and Histopathological Changes 90
Treatment 91
Conclusions 92
References 92
Chapter 10: Myogenic Ptosis 94
Introduction 94
Congenital Myogenic Ptosis 94
Acquired Myogenic Ptosis 109
Evaluation of the Patient 116
Treatment 118
References 120
Chapter 11: Myasthenia Gravis 122
Overview 122
Diagnosis: Clinical 123
Diagnosis: Testing 124
Medical Therapy 126
Surgical Therapy 127
References 128
Chapter 12: Neurogenic Blepharoptosis 130
Introduction 130
Cortical and Supranuclear Blepharoptosis 130
Third Nerve (Oculomotor) Palsy 131
Diagnosis 131
Localization of a Third Nerve Palsy 133
Common Etiologies for Third Nerve Palsy 135
Treatment of Blepharoptosis in Third Nerve Palsy 135
Horner Syndrome 136
Diagnosis 136
Pharmacologic Evaluation 137
Localization of Horner Syndrome 138
Radiographic Evaluation 140
Horner Syndrome in Children 141
Treatment 142
References 142
Chapter 13: Traumatic Blepharoptosis 144
Introduction 144
Etiology and Mechanisms of Traumatic Ptosis 144
Iatrogenic Causes of Ptosis 144
Ptosis Postintraocular Surgery 144
Ptosis Posteyelid and Adnexal Procedures 145
Contact Lens Wear 146
Ptosis Following Systemic Interventions 147
Birth Trauma 147
Blunt Trauma 148
Lacerating Trauma 148
Traumatic Ptosis Secondary to Restrictive Scarring 148
Traumatic Ptosis Following Facial Fractures 148
Neurogenic Ptosis Secondary to Trauma 152
Traumatic Superior Orbital Fissure Syndrome 152
Blepharoptosis Secondary to Traumatic Third Nerve Palsy 152
Isolated Neurogenic Ptosis 153
Traumatic “Ptosis” Secondary to Facial Synkinesis 153
Management of Traumatic Blepharoptosis 153
References 154
Chapter 14: Anophthalmic Ptosis 156
Etiology 156
Evaluation 158
Solutions 159
Conclusion 159
References 160
Chapter 15: Lash Ptosis 161
Introduction 161
Pathophysiology 161
Clinical Evaluation 162
Surgical Management 162
Minimal Lash Ptosis 164
Moderate to Severe Lash Ptosis 164
Conclusion 164
References 165
Part IV:Treatment 166
Chapter 16: The Nonsurgical Treatment of Ptosis 167
Introduction 167
Patient Selection: Etiological Disease 167
Patient Selection: Other Considerations 168
Mechanical Measures 169
Lid Crutches 169
Eyelid Taping 170
Glues 170
Medical Measures: Topical Medication 170
Apraclonidine 170
Epinephrine, Dipivefrin and Phenylephrine 171
Medical Measures: Botulinum Toxin 172
References 173
Chapter 17: External Levator Resection 174
Introduction 174
Procedure 174
Conclusion 183
Suggested Reading 183
Chapter 18: Minimal Dissection, Small Incision Ptosis Correction 185
Introduction 185
Principle of the Procedure 185
Methodology of the Procedure 185
Why Should This Procedure Be Adopted When the One You Are Using Seems Satisfactory? 188
References 188
Chapter 19: Müller’s Muscle-Conjunctival Resection (Posterior Approach) 189
Technique [5] 190
References 197
Chapter 20: Open-Sky (Anterior Approach) Müller’s Muscle Resection for the Correction of Blepharoptosis 198
Introduction 198
Surgical Technique 199
Preservation of the Conjunctiva 199
Open-Sky Müller’s Muscle Resection and the Phenylephrine Test 200
Discussion 201
References 203
Chapter 21: The Fasanella–Servat Procedure for Ptosis 205
History 205
Mechanism of Action 205
Indications 206
Procedure 206
Description of the Procedure 206
Complications 209
Discussion 212
References 212
Chapter 22: Full-Thickness Eyelid Resection for Blepharoptosis Correction 214
Indications 215
Techniques 216
Lamellar Technique 217
En Bloc Technique 218
Challenges and Solutions 218
Pearls 221
References 222
Chapter 23: Frontalis Suspension for the Correction of Blepharoptosis 223
Indications 223
Autologous Tissue for Frontalis Suspension 223
Autogenous Fascia Lata 223
Harvesting Fascia Lata 224
Temporalis Fascia 224
Harvesting Deep Temporalis Fascia 224
Palmaris Longus Tendon 225
Harvesting Palmaris Longus Tendon 226
Frontalis Muscle Flap Advancement 226
Allografts for Frontalis Suspension 226
Preserved Fascia Lata 226
Other Processed Tissues 226
Synthetic Materials for Frontalis Suspension 226
Techniques for Frontalis Suspension 228
Double Triangle or Rhomboid Frontalis Sling 229
Single Pentagonal Frontalis Sling 230
References 233
Part V:Other Considerations 234
Chapter 24: In-Office Surgery, Anesthesia, and Analgesia 235
The Transition to Office-Based Surgery 235
Reasons to Transition 235
Surgical Space and Equipment 235
State Regulations 236
Procedure Selection 237
Patient Selection 237
Evaluating Patients at Risk for Anxiety 238
Nonmedical Prevention of Anxiety 239
Medical Prevention of Anxiety 239
Postoperative Nausea and Vomiting 240
Anesthesia for Surgery 241
Topical Anesthetics 241
Injectable Anesthetics 242
Postoperative Pain Control 243
Conclusion 244
References 245
Chapter 25: Ethnic and Gender Considerations in Ptosis Surgery 246
Gender Considerations in Ptosis Surgery 246
Ethnic Considerations in Ptosis Surgery 248
References 251
Chapter 26: Aesthetic Considerations for the Ptosis Surgeon 252
References 254
Chapter 27: Challenging Ptosis Scenarios 255
Benign Essential Blepharospasm and Hemifacial Spasm 255
Etiology and Evaluation 255
Treatment 257
Surgical Technique 258
Aporneurotic Ptosis Repair 258
Frontalis Sling 258
Complications 258
Summary 259
Tarsal Switch 259
Eyelid Laxity and Tarsal Insufficiency 261
Severe Horizontal Eyelid Laxity 261
Inadequate Tarsus 261
Neurofibromatosis 262
References 264
Chapter 28: Ptosis Surgery: Comparing Different Surgical Techniques 265
Involutional/Aponeurotic ptosis 265
Levator Advancement/Plication 265
Müller Muscle Conjunctival Resection 266
Congenital Myogenic Ptosis 267
Frontalis Suspension 267
Levator Resection 267
Maximal Levator Resection 269
Whitnall’s Sling 269
Summary 269
References 269
Chapter 29: Ptosis Surgery Failure and Reoperation 271
Introduction 271
Factors Increasing Ptosis Surgery Failure 272
Preoperative Factors 272
Intraoperative Factors 272
Postoperative Factors 274
Surgical Approach to Ptosis Reoperation 274
Summary 275
References 276
Chapter 30: Complications of Ptosis Repair: Prevention and Management 277
Under- and Overcorrection 277
Entropion 280
Symblepharon 282
Ectropion 283
Contour Deformity 284
Lagophthalmos 286
Eyelid Fold and Crease 286
Conjunctival Prolapse 287
Hemorrhage/Hematoma 287
Infection 288
Corneal Abrasion/Ulceration/Perforation 289
Conclusion 289
References 289
Chapter 31: Commentary: Perspective of a Risk Manager: 12 Steps of a Successful Surgical Encounter 290
Twelve Steps to a Successful Surgical Encounter 291
Chapter 32: Conclusion 302
Index 303