Ptosis

What is Ptosis

Ptosis is an abnormally low position (drooping) of the upper eyelid
The drooping may be worse after being awake longer, when the individual's muscles are tired.
This condition is sometimes called "lazy eye", but that term normally refers to amblyopia.
If severe enough and left untreated, the drooping eyelid can cause other conditions, such as amblyopia or astigmatism.
This is why it is especially important for this disorder to be treated in children at a young age, before it can interfere with vision development.



There are two 'main' surgeries that may be performed on the upper eyelid. This section addresses Ptosis which is the medical term for drooping of the upper eyelid; it may affect one or both eyes.
The other surgery of the upper eyelid addresses excess skin is repaired by blepharoplasty.

Ptosis occurs when the muscles that raise the eyelid (levator and Müller's muscles) are not strong enough to do so properly. It can affect one eye or both eyes and is more common in the elderly, as muscles in the eyelids may begin to deteriorate.

Ptosis can be caused by the apneurosis of the levator muscle, nerve abnormalities, trauma, inflammation or lesions of the lid or orbit.
Dysfunctions of the levators may occur as a result of a lack of nerve communication being sent to the receptors due to antibodies needlessly attacking and eliminating the neurotransmitter.
Ptosis may be due to a myogenic, neurogenic, aponeurotic, mechanical or traumatic cause and it usually occurs isolated, but may be associated with various other conditions, like immunological, degenerative, or hereditary disorders, tumors, or infections
Acquired ptosis is most commonly caused by aponeurotic ptosis. This can occur as a result of senescence, dehiscence or disinsertion of the levator aponeurosis. Moreover, chronic inflammation or intraocular surgery can lead to the same effect. Also, wearing contact lenses for long periods of time is thought to have a certain impact on the development of this condition.
Congenital neurogenic ptosis is believed to be caused by the Horner syndrome.
In this case, a mild ptosis may be associated with psilateral ptosis, iris and areola hypopigmentation and anhidrosis due to the paresis of the Mueller muscle. Acquired Horner syndrome may result after trauma, neoplastic insult, or even vascular disease.
Ptosis due to trauma can ensue after an eyelid laceration with transection of the upper eyelid elevators or disruption of the neural input.
Other causes of ptosis include eyelid neoplasms, neurofibromas or the cicatrization after inflammation or surgery. Mild ptosis may occur with aging.




Acquired Ptosis

Acquired ptosis is most commonly caused by aponeurotic ptosis. This can occur as a result of senescence, dehiscence or disinsertion of the levator aponeurosis. Moreover, chronic inflammation or intraocular surgery can lead to the same effect. Also, wearing contact lenses for long periods of time is thought to have a certain impact on the development of this condition.

Aponeurotic ptosis may require surgical correction if severe enough to interfere with vision or if cosmesis is a concern. Treatment depends on the type of ptosis and is usually performed by an ophthamolic plastic and reconstructive surgeon, specializing in diseases and problems of the eyelid.

Ptosis that is caused by a disease (such as Myasthenia Gravis) will improve if the disease is treated successfully.


Treatment

Surgical procedures include: Correction of acquired ptosis may be performed in a number of different ways.

Levator resection (Anterior/External approach)

  • Skin incision
  • Adjustment is based on eyelid position during surgery patient is awake
  • May be combined with cosmetic upper blepharoplasty

Müller muscle resection (Poster / Internal approach)

  • Ideal for patients with minimal excess skin
  • No visible skin incision
  • May be combined with cosmetic upper blepharoplasty

Frontalis sling operation

  • Required when the degree of ptosis is severe
  • Creates a ‘sling’ from the frontalis muscle (brow) to the eyelid.
  • Often performed for congenital ptosis
  • Allows patient to be asleep since surgical repair is based on formula



Ptosis with Acquired Horners

Horner's syndrome or Horner syndrome is a clinical syndrome caused by damage to the sympathetic nervous system. It is also known by the names Bernard-Horner syndrome or Claude Bernard-Horner syndrome or as oculosympathetic palsy.

  • Signs found in all patients on affected side of face include ptosis (drooping upper eyelid from loss of sympathetic innervation to the Müller or superior tarsal muscle, upside-down ptosis (slight elevation of the lower lid), and miosis (constricted pupil) and dilation lag.
  • Enophthalmos (the impression that the eye is sunk in) and anhydrosis (decreased sweating) on the affected side of the face, loss of ciliospinal reflex and blood shot conjunctiva may occur depending on the site of lesion.
  • Also flushing of the face is common on the affected side of the face due to dilation of blood vessels under the skin.

In children Horner syndrome sometimes leads to a difference in eye color between the two eyes (heterochromia). This happens because a lack of sympathetic stimulation in childhood interferes with melanin pigmentation of the melanocytes in the superficial stroma of the iris.


Pathophysiology

Horner syndrome is due to a deficiency of sympathetic activity. The site of lesion to the sympathetic outflow is on the ipsilateral side of the symptoms. The following are examples of conditions that cause the clinical appearance of Horner's syndrome:

  • First-order neuron disorder: Central lesions that involve the hypothalamospinal pathway (e.g. transection of the cervical spinal cord).
  • Second-order neuron disorder: Preganglionic lesions (e.g. compression of the sympathetic chain by a lung tumor).
  • Third-order neuron disorder: Postganglionic lesions at the level of the internal carotid artery (e.g. a tumor in the cavernous sinus).

If someone has impaired sweating above the waist affecting only one side of the body, yet they do not have a clinically apparent Horner's syndrome, then the lesion is just below the stellate ganglion in the sympathetic chain.



Ptosis with Marcus Gun Jaw Wink

Marcus Gunn Jaw wink ptosis is an example of synkinesis (an abnormal innervation connecting two groups of normally UNRELATED muscles)

Marcus Gunn Jaw-wink ptosis does not generally improve with time, but children do tend to learn how to minimize the appearance

The phenomena is thought to be due to a congenital misdirection of the fifth cranial nerve fibers into a branch of the third cranial nerve that supplies levator muscle.


Features

Marcus Gunn Jaw wink ptosis is an example of synkinesis (an abnormal innervation connecting two groups of normally UNRELATED muscles)poor levator function   - This causes the eyelid to open (increase in the palbebral fissure) with movements of the mouth
higher position of the ptotic eyelid on downgaze.
Children with significant ptosis may need to tilt their head back into a chin-up position, lift their eyelid with a finger, or raise their eyebrows in an effort to see from under their drooping eyelid(s).
Marcus Gunn Jaw-wink ptosis does not generally improve with time, but children do tend to learn how to minimize the appearance


Causes

While the cause of Congenital ptosis is often unclear, the most common reason is improper development of the levator muscle. The levator muscle is the major muscle responsible for elevating the upper eyelid.
Children with Congenital ptosis may also have amblyopia ("lazy eye"), strabismus (eyes that are not properly aligned or straight), refractive errors, astigmatism, or blurred vision. In addition, drooping of the eyelid may result in an undesired facial appearance.


Evaluation of the Patient

complete ophthalmic exam with particular attention to visual acuity.

  • In a series of Congenital ptosis cases incidence of amblyopia was measured to be 20% of which 3% was attributable to droopy eyelid.
  • In the past, the chin elevation posturing was considered a sign of fusion and, thus, indicating a low risk for amblyopia.
  • However, it has recently been shown that the chin elevation does not rule out the presence of significant amblyopia.

thorough motility examination is essential

  • in a series of a 113 patients, 31% were found to have strabismus and of these, 3% of the cases were believed to be caused by ptosis that disrupted binocular fusion.
  • because the superior rectus is often involved, full extraocular motion needs to be carefully evaluated.

Concurrent Anatomic Abnormalitites

Blepharophimosis may require medial canthal tendon plication5
Physiologic defects such as jaw-winking ptosis may require transection of the levator muscle as well as frontalis suspension.
Because of the levator aponeurosis resection, children needs to be performed under general anesthesia, a formula is used to determine the amount of levator aponeurosis resection.


Treatments

In general, if the visual axes are not obscured by the ptotic lid, it is best to defer treatment until the child is age 3 or 4.

The surgical procedure is determined by the amount of levator function present and the severity of ptosis. Function is typically categorized as poor (less than 4 mm), fear (5 to 7 mm) and good (more than 8 mm). In cases of severe ptosis in less than 2 mm of levator function, suspension of the lid to frontalis muscle is the procedure of choice.Congenital Ptosis is treated surgically, with the specific operation based on the severity of the ptosis and the strength of the levator muscle.

  • Conjunctival-muellers resection
  • Levator resection
  • Frontalis sling
    • Silicone
    • Fascia (autogenous or donor)
    • Supramid

If the ptosis is not severe, surgery is generally performed when the child is between 3 and 5 years of age (the "pre-school" years).

However, when the ptosis interferes with the child's vision, surgery is performed at an earlier age to allow proper visual development.

Congenital ptosis is most often treated by ophthalmic plastic and reconstructive surgeons who specialize in disease and conditions affecting the eyelids, lacrimal (tear) system, the orbit (bone cavity around the eye), and adjacent facial structures.



Myasthenia Gravis

Myasthenia gravis is a clinical condition where antibodies are generated within the body that attack the junctions between the nerves and the muscles, resulting in muscle weakness and tiredness. At the junction of the nerves and muscles (also called neuromuscular junction) are receptors called acetylcholine receptors. These receptors have the capability of binding to acetylcholine, a neurotransmitter that helps promote conduction of electrical impulses from the nerves to the muscle. Blocking of these in myasthenia gravis is what results in the clinical features.

In this article, we shall briefly discuss the signs and symptoms of myasthenia gravis, and touch upon the different management options available.



Clinical features

Patients with myasthenia gravis experience the typical feature of muscle fatigue. The muscles become weaker with time, and are particularly vulnerable when undergoing continuous activity. One of the muscle groups that are often involved is the eyelid. Patients have droopy eyelids - a condition called ptosis. This can affect one or both of the eyelids and can have additional effects such as double vision. This is called ocular myasthenia.

Other symptoms that may be seen include slurred speech, difficulty walking, weakness of the muscles of the arms and legs, difficulty swallowing and even muscles that are required for breathing (in advanced cases).



Pathophysiology

The main underlying defect in myasthenia gravis (as described briefly above) is autoimmunity. This means that there are antibodies within the body that act against the individual’s own proteins. These antibodies are called auto-antibodies. There is some genetic link in myasthenia, though in most cases the underlying abnormality lies within a gland in the chest called the thymus gland. The auto-antibodies act against the acetylcholine receptor, thus interrupting normal neuromuscular unction function. This causes muscle weakness.



Diagnosis

Most cases of myasthenia gravis, particularly ocular myasthenia can be diagnosed by clinical history and physical examination. A simple bedside test can be performed where the patients are asked to look up at a point (or pencil) by only elevating their eyes and keeping their head still. In a few seconds, the muscles of the eyelid become weak and start to droop, resulting in ptosis. Blood tests may be performed to identify the antibodies. Electromyography tests that assess conduction of nerve impulses in the muscles is also a useful tests.

In ocular myasthenia, the edrophonium test may sometimes be used. It is based on the principle that injection of edrophonium chloride will temporarily reverse ptosis in myasthenia patients, and not it other causes of ptosis.



Treatment

Medical treatment includes acetylcholinesterase enzyme blockers such as neostigmine and pyridostigmine. These drugs are useful in managing muscle weakness effectively, and are often started by the doctor in small doses. Stronger medications such as steroids, mycophenolate mofetil and azathioprine suppress the immune system and reduce the production of antibodies and are useful as well.

Special treatments include plasmapheresis - a procedure that helps remove these antibodies from the body. Intravenous immunoglobulin can also be used to eliminate these antibodies by binding to them. Finally, removal of the thymus gland may also be offered - a procedure called thymectomy.

Surgery to elevate the eyelid may also be performed.



Conclusion

Myasthenia gravis is a condition that affects the muscles, particularly the eyes. Diagnosis is fairly straight forward, and treatment options are many.



Surgical Techniques

Surgical procedures include: Correction of acquired ptosis may be performed in a number of different ways.

Ptosis can be caused by the apneurosis of the levator muscle, nerve abnormalities, trauma, inflammation or lesions of the lid or orbit.

Dysfunctions of the levators may occur as a result of a lack of nerve communication being sent to the receptors due to antibodies needlessly attacking and eliminating the neurotransmitter.

Ptosis may be due to a myogenic, neurogenic, aponeurotic, mechanical or traumatic cause and it usually occurs isolated, but may be associated with various other conditions, like immunological, degenerative, or hereditary disorders, tumors, or infections.

Acquired ptosis is most commonly caused by aponeurotic ptosis. This can occur as a result of senescence, dehiscence or disinsertion of the levator aponeurosis. Moreover, chronic inflammation or intraocular surgery can lead to the same effect. Also, wearing contact lenses for long periods of time is thought to have a certain impact on the development of this condition.

Congenital neurogenic ptosis is believed to be caused by the Horner syndrome.

In this case, a mild ptosis may be associated with psilateral ptosis, iris and areola hypopigmentation and anhidrosis due to the paresis of the Mueller muscle. Acquired Horner syndrome may result after trauma, neoplastic insult, or even vascular disease.

Ptosis due to trauma can ensue after an eyelid laceration with transection of the upper eyelid elevators or disruption of the neural input.

Other causes of ptosis include eyelid neoplasms, neurofibromas or the cicatrization after inflammation or surgery. Mild ptosis may occur with aging.




Levator resection (Anterior/External approach)

  • Skin incision
  • Adjustment is based on eyelid position during surgery patient is awake
  • May be combined with cosmetic upper blepharoplasty

Müller muscle resection (Poster / Internal approach)

  • Ideal for patients with minimal excess skin
  • No visible skin incision
  • May be combined with cosmetic upper blepharoplasty
  • Candidates for this procedure respond to 2.5% phenylephine place behind the upper eyelid. See slider animation below.



Frontalis sling operation

  - The idea of the frontalis sling procedure is to transfer the elevating function of the ptotic eyelid to the frontalis muscle.
  - Required when the degree of ptosis is severe
  - To achieve this, the eyelid is directly suspended to the brow using various materials.Creates a ‘sling’ from the frontalis muscle (brow) to the eyelid.

  • synthetic materials, such as ptoseup, Supramid suture, Gortex, silicone, or Mersilene mesh may also be used.
  • Fascia (autogenous or donor using material such as BioElevation™ Ptosis Slings
  - performed for congenital ptosis
  - Because the sling material has little elasticity, a tethering effect on downgaze, Lagophthalmosxare expected postoperatively
  - Allows patient to be asleep since surgical repair is based on formula

Procedures
Anophthalmos
- Anophthalmia is a medical term used to describe the absence of the globe and ocular tissue from the orbit. - This was first reported more than 400 years ago, yet it is only recently that significant reconstructive options became available. - There are many reasons why one might lose an eye. - Surgeries which result in anophthalmos
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Blepharoplasty
What is Blepharoplasty?
- Your eyes including your eyelids, are perhaps one of the first things people notice in you. This makes your eyes and eyelids one of the most important components for an appealing facial expression and aesthetic appearance. Any visible change in the shape or size of the orbital or periorbital region can spoil the look of your face.
- As you age and grow older, your eyelids may become ‘droopy’ or ‘baggy’ due to the stretching of your eyelid skin and gradually decreasing tone of your eyelid muscles. Your droopy eyelids and brow together cut a sorry figure for your face making you look tired, sleepy and haggard, further leading to eyelid or brow straining or both. In extreme cases, your saggy, baggy eyelids can even obstruct your vision, particularly peripheral vision causing difficulty in reading or driving.
- Blepharoplasty ensures cosmetic or functional corrections to the area around your eyes to enhance your look or to correct any abnormalities in function.
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Blepharospasm
- Blepharospasm is defined as an abnormal, involuntary, sustained and forceful closure or twitching of the eyelids. It is derived from the Greek word ‘blepharon’ which means eyelid, and ‘spasm’ which is an uncontrolled muscle contraction. Blepharospasm is usually associated with headache, eyebrow strain and occasionally loss of vision.
- Isolated blepharospasm is rare and represents a minority of patients presenting with blepharospasm. Blepharospasm is commonly associated with lower facial spasms as part of a syndrome or disease complex. Some examples are:
   - Meige Syndrome: Characterized by spasm of the eyelids and midface.
    - Brueghel’s Syndrome: Presents with blepharospasm and marked spasms in the lower face and neck.
    - Segmental Cranial Dystonia: In addition to the usual spasms of the eyelids and facial muscles it is associated with spasms along distribution of various cranial nerves, most frequently involving the Facial Nerve.
    - Generalized Dystonia: Presents with spasms across various body parts in addition to blepharospasm and facial spasms.
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Brow Lift
A forehead lift, also known as a browlift or browplasty, is a cosmetic surgery procedure used to elevate a drooping eyebrow that may obstruct vision and/or to remove the deep worry lines that run across the forehead and may portray to others anger, sternness, hostility, fatigue or other unintended emotions
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Congenital
Congenital anomolies include :
- Eyelid Disorders
- Orbital Disorders
- Congenital Ptosis
- Congenital Nasolacrimal Duct Obstruction

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Dry Eye
What is Dry Eye?
- Dry eye is a reduction in your eye’s ability to produce sufficient natural tears.
- Insufficient tear production can lead to irritation and pain, and even scarring of the cornea (the transparent part of the eye that covers the pupil and iris).
- Many people will experience dry eye symptoms at some point in their lives.
- Often due to environmental factors such as indoor heating or air conditioning, it can also be caused by occupational factors such as prolonged computer use.
- Dry eye symptoms can affect anyone.
- Some of the symptoms of dry eye include a burning sensation or gritty feeling in the eyes. You may also experience decreased tolerance to contact lens wear or sensitivity to light.
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Eyelid Laxity
- Eyelids protect your eyes from any foreign bodies while keeping them lubricated throughout. Any alteration in the shape, position or function of your eyelids can predispose your eyes to a plethora of ailments or interfere with our vision.
Our eyelid is a complex structure consisting of three theoretical layers:
   - Anterior Layer contains the skin and orbicularis muscle
   - Middle Layer contains the orbital septum and eyelid retractors
   - Posterior Layer contains tarsus and conjunctiva.

- Eyelid malpositions include any unnatural or incorrect positioning and orientation of eyelids due to various factors that influence any of the three layers of the eyelids. They may be caused due to ageing, trauma, scarring, birth defects or medical disease involving any or all of the three layers.
- The most common forms of eyelid malposition are eyelid retraction, ptosis, entropion and ectropion.
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Face
The world of cosmetic surgery has advanced tremendously over the last two decades. New procedures have emerged that can make an individual look and feel younger in a matter of a few minutes. Amongst the vast number of cosmetic procedures currently available, the face lift is a commonly performed one that is sought after by both men and women. Here we shall take a look at this procedure in a little more detail.

- What is a face lift?    - A face lift is called a rhytidectomy in the world of medicine. It involves tightening the muscles of the face and smoothening of the skin so that the face appears younger.    - However, it must be remembered that a face-lift is not an anti ageing solution.
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Lacrimal System
- The lacrimal gland produces tears which enter into the "duct" that drain the tears from the eye into the nose. The most common symptoms are If one has a plugged up "tear duct," not only will tears spill over the eyelids and run down the face, but the stagnant tears within the system can become infected.    (1) excess tearing (tears may run down the face) and    (2) mucous discharge - This may lead to recurrent red eyes and infections. - The excessive tearing can also produce secondary skin changes on the lower eyelids.
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Lagophthalmos
Patients with lagophthalmos have an inability to close eyelids. This may occur, for instance, in patients with Thyroid eye disease.
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Latisse
LATISSE® makes lash growth possible because of its active ingredient: bimatoprost. Although the precise mechanism of action is not known, research suggests that the growth of eyelashes occurs by increasing the percent of hairs in, and the duration of, the anagen (or growth) phase. Lashes can grow longer, thicker and darker because bimatoprost can also prolong this growth phase.
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Orbital Tumors
- Orbital Tumor is any tumor that occurs within the orbit of the eye. The orbit is a bony housing in the skull about 2 inches deep that provides protection to the entire eyeball except the front surface. It is lined by the orbital bones and contains the eyeball, its muscles, blood supply, nerve supply, and fat.
- Tumors may develop in any of the tissues surrounding the eyeball and may also invade the orbit from the sinuses, brain, or nasal cavity, or it may metastasize (spread) from other areas of the body. Orbital tumors can affect adults and children. Fortunately, most are benign.
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Ptosis
- Ptosis is an abnormally low position (drooping) of the upper eyelid
- Ptosis occurs when the muscles that raise the eyelid (levator and Müller's muscles) are not strong enough to do so properly.
- It can affect one eye or both eyes and is more common in the elderly, as muscles in the eyelids may begin to deteriorate.
- Compare with dermatochalsis (extra skin and fat)
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Skin Rejuvination
A radiant, smooth, youthful skin is the essence of beauty and trendy looks. Skin care routine highly contributes in the slowing down of rate of aging of the skin. Choosing the right skin care products for your skin type enhances your beauty keeping the skin cleansed, moisturized and well toned. Use of superficial skin resurfacing treatments to counter fine lines and wrinkles, acne scars and blemishes before they deepen ensures skin rejuvenation.
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Skin Tumors
Cancer of the eyelid, like any other cancer, can be a worrying thing. Treatments are variable and depend on the type of cancer. In this article, we shall take a brief look at the different kinds of eyelid tumors.
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Symblepharon
A symblepharon is a fibrous tract that connects bulbar conjunctiva to conjunctiva on the eyelid.
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Thyroid
Graves' disease is an autoimmune disease.
It most commonly affects the thyroid, causing it to grow to twice its size or more (goiter), be overactive, with related hyperthyroid symptoms such as increased heartbeat, muscle weakness, disturbed sleep, and irritability. It can also affect the eyes, causing bulging eyes (exophthalmos).
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Trauma
Eye injuries are extremely common with over 2 million cases reported every year that require medical treatment. Blindness in one eye is most commonly due to cataract and this is followed closely by eye injuries. In addition, in children, injury to the eye is a recognized as the most common cause of blindness in one eye that is not due to a birth defect.
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