Blepharoptosis Repair
Roshni Ranjit-Reeves, MD
DISEASE DESCRIPTION
Blepharoptosis is a low-lying upper eyelid margin. Blepharoptosis becomes visually significant if the lid margin obstructs the superior border of the pupil; this usually corresponds to a margin-reflex distance 1 (MRD1) of less than 2 mm. Establishing the diagnosis and underlying pathology is key to guiding the surgical approach. There are numerous causes of ptosis and, subsequently, many classification schemes exist. Blepharoptosis can be acquired or congenital.
Acquired
Aponeurogenic (most common)
Involutional — age-related anatomic changes
Contact lens use
Myogenic
Chronic progressive external ophthalmoplegia (CPEO)
Oculopharyngeal muscular dystrophy (OPMD)
Myotonic dystrophy
Post neurotoxin
Mechanical
Lid edema
Lid lesion
Neurogenic
Cranial nerve (CN) III palsy
Horner’s syndrome
Multiple sclerosis
Myasthenia gravis
Ophthalmic migraine
Traumatic
Birth trauma
Blunt trauma
Iatrogenic
Pseudoptosis
Congenital
Congenital ptosis is most commonly isolated and results from dysgenesis of the levator palpebrae superioris. It may occur alone (simple congenital ptosis) or in conjunction with dysgenesis of the superior rectus muscle. Less commonly, congenital ptosis occurs as a result of genetic or chromosomal abnormalities, as part of a syndrome, or as a result of neurologic dysfunction.
Simple congenital ptosis
Marcus Gunn syndrome — ipsilateral synkinesis of the motor division of CN V (to lateral pterygoid) to the superior division of CN III resulting in eyelid elevation with mastication and/or movement of the jaw to the opposite side
Blepharophimosis syndrome — ptosis, epicanthus inversus, telecanthus
Congenital cranial nerve III palsy
Congenital Horner’s syndrome
PREOPERATIVE EVALUATION
A thorough history and physical examination will help establish the underlying cause of blepharoptosis. Elements of the evaluation that will help distinguish etiologies and guide management decisions include the following:
History
Age of onset (congenital vs. acquired)
Old photo evaluation for comparison
Effect on daily activities
Variable or fluctuating symptoms
History of strabismus or amblyopia
Recent trauma or ophthalmic procedure
Associated diplopia (myasthenia gravis, third nerve palsy, CPEO)
Difficulty swallowing (OPMD)
Family history of ptosis (congenital, blepharophimosis, OPMD, CPEO, muscular dystrophy [MD])
Generalized weakness (myasthenia gravis, OPMD, MD)
Examination
Eyelid position — MRD1 measured with the skin of the eyelid gently elevated from the lid margin to eliminate the contribution of dermatochalasis and brow ptosis.
Levator function (will be decreased in congenital, neurogenic, and myogenic cases). Normal levator function is 10 to 15 mm. Levator function less than 5 mm requires frontalis suspension.
Brow position (compensatory activation)
Upper lid dermatochalasis (may require concurrent blepharoplasty)
Frontalis function (if planning sling procedure)
Lid crease configuration — the absence of a lid crease is pathognomonic of congenital ptosis because of the lack of levator function.
Pupillary evaluation (anisocoria suggests Horner’s syndrome)
Motility evaluation (ophthalmoplegia, congenital fibrosis of extraocular muscles)
Fatigability of levator function and MRD1 with upgaze (myasthenia gravis)
Cogan lid twitch (In suspected myasthenia patients, ask the patient to look in downgaze and then upgaze. The affected eyelid will overshoot on upgaze.)
Response of ptosis to ice
Orbicularis oculi function
Lagophthalmos
Presence of epicanthus inversus and telecanthus (blepharophimosis syndrome)
Associated jaw-winking (Marcus Gunn syndrome)
Phenylephrine 2.5% test (if considering conjunctivomüllerectomy)
Bell’s phenomenon
Corneal sensation (Hypesthesia or anesthesia warrants conservative lifting.)
Tear film, tear meniscus height, tear breakup time (Consider more conservative lifting in patients with dry eyes.)
Basal tear secretion test — anesthetize the eyes with topical drops and place a small strip of filter paper in the inferior fornix for 5 minutes (10-15 mm of wetting is normal; less than 5 mm of wetting is significant and warrants conservative lifting.)
It is important to do ice testing (ice placed on eyelids for 5 minutes) in the office and take pre- and postoperative photographs to demonstrate ptosis changes if concerned for ocular myasthenia gravis, which can present with variable ptosis and diplopia.
The lid crease in Asian patients may be highly variable. In general, Asian eyelids tend to have lower lid creases, but may have no lid crease, a lower lid crease, or a higher lid crease. The lid crease configuration may differ between members of the same family and sometimes even between a patient’s two eyes. Therefore, a thorough discussion of expectations should be taken before planning surgery.
Wait at least 6 months after traumatic ptosis before planning levator repair. Allowing time for levator function to stabilize will help improve predictability of the result.
MANAGEMENT OPTIONS
Most cases of blepharoptosis are repaired surgically by levator advancement, conjunctivomüllerectomy, or a frontalis sling procedure. The choice of procedure depends on the underlying etiology and eyelid function (levator and orbicularis function).
Levator function greater than 10 mm — levator advancement (or conjunctivomüllerectomy if there is a positive phenylephrine test)
Levator function less than 6 mm — frontalis sling
Surgical choice in cases with levator function between those numbers is determined by surgeon preference and depends on the degree of ptosis. For example, a patient with 9 mm of levator function and 1.5 mm of ptosis will likely benefit from levator advancement, whereas a patient with 7 mm of levator function and 3 mm of ptosis will likely do better with a frontalis sling.
Mild ptosis in patients who are high-risk surgical candidates — consider topical apraclonidine 0.5% twice daily as needed.
Pseudoptosis from orbicularis overaction — chemodenervation
INDICATIONS FOR SURGERY
Visually significant blepharoptosis
Cosmetically bothersome blepharoptosis
Amblyogenic congenital blepharoptosis
SURGICAL DESCRIPTION
Levator Aponeurosis Advancement
Induce the patient with monitored intravenous anesthesia.
Mark the upper lid crease. Mark the point on the eyelid margin corresponding to the visual axis as well. Inject up to 2 mL of local anesthetic (equal parts 1%-2% lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine without epinephrine).
Incise the upper lid crease along the marked skin site with a #15 blade.
Using Westcott scissors, dissect down to the anterior surface of the tarsal plate. Be certain to dissect through all epitarsus, down to bare tarsus (Figure 7.1).
Identify the terminal aspect of the levator aponeurosis and reflect it off the superior aspect of the tarsal plate. Place Westcott scissors flush against the tarsal plate just inferior to the insertion of the levator aponeurosis with the tips pointed superiorly. Sharply dissect in a superior direction to separate the levator aponeurosis from the tarsal plate. Once the dissection proceeds beyond the tarsal plate, use blunt dissection to separate the levator aponeurosis from the underlying Müller muscle. Dissect until the level of Whitnall’s ligament (Figure 7.2).
Just medial to the visual axis, pass a 6-0 Vicryl suture on a spatula needle through the underside of the levator aponeurosis and then pass the needle through the tarsus in a partial-thickness fashion. Make the tarsal pass approximately 3 to 4 mm from the superior border of the tarsus. Tie the suture in a temporary manner using a slip knot (Figure 7.3).
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