FPRS Ptosis and blepharoplasty

Question 1

What are the four standard clinical measurements

used for evaluating someone with ptosis?

Answer 1

● Palpebral fissure height
● Marginal reflex distance
● Upper eyelid crease distance
● Levator excursion

Question 2

How does one assess eyelid ptosis?

Answer 2

Eyelid ptosis should be evaluated in primary gaze with the frontalis relaxed and the brow fixed. The average vertical
palpebral fissure is approximately 10 mm. The levator function is tested by measuring the vertical excursion of the eyelid (normal 12 to 18 mm). The margin-to-reflex distance is the distance between the central corneal light reflex and the upper eyelid margin (normal ~ 4.5 mm).

Question 3

What is the normal position of the upper eyelid

relative to the limbus?

Answer 3

The upper eyelid margin typically rests 1.5 mm below the superior corneal limbus, with the highest point just medial to the pupil.

Question 4

Describe the ideal upper eyelid configuration.

Answer 4

The lid crease is 6 to 8 mm from the lash line in a man and 8
to 10 mm in a woman. The upper lid covers approximately
1.5 mm of the iris and does not reach the level of the pupil
during primary gaze.

Question 5

What two muscles are responsible for elevation of

the upper eyelid?

Answer 5

Levator palpebrae superioris and Müller muscle

Question 6

Where does the levator palpebrae superioris

originate and insert?

Answer 6

It originates from the lesser wing of the sphenoid and

inserts on the superior tarsal plate.

Question 7

What is the innervation of the levator palpebrae

superioris?

Answer 7

The oculomotor nerve

Question 8

Where does Müller muscle originate and insert?

Answer 8

It originates from the undersurface of the levator palpebrae

superioris and inserts on the superior aspect of the tarsus.

Question 9

What is the innervation of Müller muscle?

Answer 9

Sympathetic nervous system from the superior cervical
ganglion to the carotid plexus and along the oculomotor
nerve

Question 10

Describe the margin crease distance.

Answer 10

The distance from the upper eyelid crease to the upper

eyelid margin measured during downgaze

Question 11

Where should the inferior incision be placed

during upper eyelid blepharoplasty?

Answer 11

At the natural lid crease, which is at the upper margin of the underlying superior tarsal plate (8 to 10 mm above the lid
margin in women and 6 to 9 mm in men)

Question 12

What are milia?

Answer 12

Milia are 1- to 2-mm cysts that appear as white, smooth
nodules on the face. Histologically, they are identical to
epidermoid cysts except for their smaller size.

Question 13

Describe the marginal reflex distance-1?

Answer 13

Distance from the center of the pupillary light reflex to the upper eyelid margin during primary gaze

Question 14

What is the marginal reflex distance-2?

Answer 14

The space between the lower eyelid margin and the

pupillary light reflex during primary gaze (normally ~ 5 mm)

Question 15

What is the difference between blepharoptosis and

blepharochalasis?

Answer 15

● Blepharoptosis (ptosis) refers to an abnormally low-lying
upper eyelid margin during primary gaze.
● Blepharochalasis refers to a condition of unilateral or
bilateral episodic painless, periorbital edema that leads to
lid redundancy.

Question 16

What is pseudoptosis?

Answer 16

When the upper eyelid appears to be low as a result of
malposition of the globe or brow rather than eyelid
dysfunction

Question 17

What is the cause of an undesirable hollowed-out

appearance after cosmetic blepharoplasty?

Answer 17

Excessive resection of orbital fat

Question 18

What is the anatomical basis for the difference

between the Asian and white upper eyelid?

Answer 18

In the Asian eyelid, the orbital septum fuses with the levator aponeurosis below the superior tarsal border. The accompanying preaponeurotic or orbital fat is allowed to proceed to the anterior tarsal surface, resulting in a full, thickened or
puffy eyelid. In the white eyelid, the levator aponeurosis penetrates the orbital septum and orbicularis muscle attaching to the overlying dermis, creating a superior palpebral fold.

Question 19

What is the primary risk of epicanthoplasty in the Asian patient?

Answer 19

Web formation in the medial canthal region

Question 20

What percentage of Asians demonstrate a “single-eyelid,” and what percentage have an epicanthal fold?

Answer 20

50% and 90%, respectively; the size of the fold is usually

relatively small.

Question 21

What is the most common form of ptosis?

Answer 21

Acquired aponeurotic or senile ptosis

Question 22

What is a common clinical sign of acquired

aponeurotic ptosis?

Answer 22

Normal or near normal levator function with an abnormally

elevated upper eyelid crease

Question 23

What is the most common type of congenital

ptosis?

Answer 23

Congenital myogenic ptosis. Caused by dysgenesis of the
levator palpebrae superioris in which the muscle fibers are
replaced by fibroadipose tissue.

Question 24

What percentage of congenital ptosis is unilateral?

Answer 24

Approximately 75%

Question 25

What coexisting ocular condition is present in a
significant number of patients with congenital
ptosis?

Answer 25

Amblyopia

Question 26

Describe the phenylephrine test for evaluating

ptosis?

Answer 26

This test involves placing dilute phenylepherine in the eye.
After waiting 5 minutes, the palpebral fissure and marginal
reflex distance are measured and compared with baseline. If
there is a good response, then the Müller muscle
conjunctival resection should be considered. If there was no
response, the external levator advancement should be considered.

Question 27

Describe the clinical manifestation of myogenic

ptosis secondary to myasthenia gravis.

Answer 27

Nearly all patients with myasthenia gravis develop ocular
symptoms, including ptosis and diplopia. Ptosis is generally
bilateral and worsens throughout the day. Symptoms may
alternate from one eye to the other.

Question 28

What surgical technique can be used for treatment of ptosis with poor or absent levator function?

Answer 28

Frontalis sling

Question 29

What are the clinical manifestations of Marcus Gunn jaw-winking ptosis?

Answer 29

Elevation of a ptotic eyelid during ipsilateral activation of the mandibular division of the trigeminal nerve (chewing,
jaw opening)