Adam J. Cohen - Evaluation and Management of Blepharoptosis

Springer Science+Business Media, LLC 2011

Adam J. Cohen 1 and David A. Weinberg

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Abstract

Blepharoptosis, or drooping of the upper eyelid, is one of the most common surgical eyelid disorders. The word ptosis, which derives from the Greek (fall or falling), refers to abnormal lowering or prolapse of an organ or body part.1 While one may apply the term ptosis to describe any anatomical structure, such as breast or chin ptosis, ptosis will be used interchangeably with blepharoptosis in this book, strictly referring to the eyelid disorder.There may be some debate as to what constitutes a ptotic eyelid. One could try to define it quantitatively, based on the margin reflex distance (MRD1), which is the distance from the corneal light reflex to the central upper eyelid margin. Yet, there is a relatively wide variation in eyelid position in the general population, and ethnic and racial differences have been described.2,3 When comparing whites, African Americans, Latinos, and Asians in a similar age bracket, whites displayed the highest mean MRD1 (5.1 mm), while Asians had the lowest (3.8 mm).2 The normal upper eyelid margin rests somewhere between the superior edge of the pupil and the superior limbus, typically around a MRD1 of 4, give or take a millimeter. There would be little argument that a MRD1 of 0 represents a ptotic eyelid, and a MRD1 of 7 indicates lid retraction. However, where does one draw the line between a normal eyelid and a ptotic eyelid? Should ptosis be defined as a MRD1 below 3 mm? 2.5 mm? 2 mm? It is more difficult to define mild ptosis precisely in individuals with symmetric upper eyelids, as opposed to those with asymmetric upper eyelids, i.e., unilateral ptosis. Another way to define ptosis is from a functional standpoint, or qualitatively. Perhaps an eyelid should be considered ptotic if it is low enough to obstruct the visual axis, i.e., below the superior edge of the pupil, since that is the primary functional consequence of ptosis. How low an upper eyelid needs to be in order to obstruct vision depends on the pupil size, and that is affected by ambient lighting conditions, degree of arousal, and systemic or topical drugs, among other factors. By this definition, an upper eyelid would not be functionally ptotic in a patient with a MRD1 of 1.52 mm and a pupil size of 3 mm, since the upper edge of the pupil is 1.5 mm above the corneal light reflex.

There is also patient perception. Some individuals may desire wider palpebral fissures that make them appear more alert, even if their vision is not obstructed by the upper eyelid position, while others may wish for the ptotic bedroom eyes look of Marilyn Monroe or Marlene Dietrich. Thus, what is normal or abnormal, and what is desirable vs. undesirable, is in the eyes of the beholder, and so treatment needs to be individualized.

Management of the ptosis patient poses challenges with respect to both diagnosis and treatment. From a diagnostic standpoint, ptosis can be the hallmark of numerous diverse and potentially serious disorders, underscoring the importance of identifying the etiology of the ptosis. This will set the framework for ptosis management and helps establish whether a patient needs surgery and what type of surgery.

There are many considerations involved in the evaluation and management of the patient with blepharoptosis. In the chapters that follow, we examine this subject from a wide range of perspectives, with the hope of providing a broad overview of this common yet complex eyelid disorder.

Springer Science+Business Media, LLC 2011

Mithra O. Gonzalez and Vikram D. Durairaj 1

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Abstract

From an inexact origin of trial and error, blepharoptosis surgery has become a scientific art. The arc of its technical development parallels that of anatomical discoveries and surgical materials. Approaches have varied, as have the tissues of interest, and with increasingly reliable results in the reconstructive domain came greater expectations and the development of its cosmetic counterpart. That said, for some diseases associated with blepharoptosis, an ideal surgery remains elusive. This chapter provides a chronological account of the treatment of blepharoptosis with attention paid to the tissues involved. The rich history of blepharoptosis surgery provides a fertile matrix for the field of oculofacial plastic surgery, and in return, the field continues to evolve blepharoptosis surgical treatment.

Keywords

The history and evolution of eyelid ptosis surgery can be analyzed in terms of chronology and tissue. A discussion of its chronology is inviting because this method allows for an understanding of the fields consecutive advances. One is able to appreciate the who, what, when, and in some cases, the more complex questions of why and how of a particular technique and understand its ultimate favor or disfavor. In a chronological discussion, one may see the subject matters natural arch, which unfortunately, can be confusing at times. On the other hand, a discussion of the tissues involved in eyelid ptosis surgery allows for an artificially coherent history by abstracting the salient subject matter from its historical context and ignoring the tempo of evolution. Such abstraction dispossess the matter of elements potentially useful to those responsible for the next generation of surgical innovations.

Authors on the history of ptosis surgery tend to use one approach or the other. Beard used the tissue approach in his writing on the history of ptosis surgery []. In this chapter, the latter approach is utilized with sensitivity paid to the tissues involved and the intention of providing the best attributes of both methods.

According to Rycroft and commonly cited in historical accounts of ptosis surgery, ancient Arabian ophthalmologists provide the first reference of eyelid surgery for the treatment of ptosis [].

On the contrary, Hirschberg argues that neither did Celsus invent a blepharoplasty nor is there any mention of such a procedure in the Greek and Roman repertoire of surgery [].

Regardless of its ancient origins, the history of ptosis surgery seems to unify with the 1806 publication of Practical Observations on the Principle and Disease of the Eye by the Italian anatomist and surgeon Antonio Scarpa. In this work, he describes a resection of integuments at the upper part of the relaxed eyelid in the vicinity and direction of the superior arch of the orbit that is intended to elevate the lid [].

Henceforth, the wealth of publications allows for a logical narration with few opportunities for conflicting opinions. After 1806, ptosis surgery undergoes many revolutions as knowledge of anatomy and physiology progresses and as types of materials expand. At its core, however, Beard keenly notes that ptosis surgery essentially falls into one of six categories: skin resection, frontalis suspension, tarsus resection, levator resection, superior rectus muscle suspension, or a combination of the aforementioned categories []. With these facts in mind, the tour of the history of ptosis surgery continues.