FPRS Ptosis and blepharoplasty Flashcards
What are the four standard clinical measurements
used for evaluating someone with ptosis?
● Palpebral fissure height
● Marginal reflex distance
● Upper eyelid crease distance
● Levator excursion
How does one assess eyelid ptosis?
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).
What is the normal position of the upper eyelid
relative to the limbus?
The upper eyelid margin typically rests 1.5 mm below the superior corneal limbus, with the highest point just medial to the pupil.
Describe the ideal upper eyelid configuration.
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.
What two muscles are responsible for elevation of
the upper eyelid?
Levator palpebrae superioris and Müller muscle
Where does the levator palpebrae superioris
originate and insert?
It originates from the lesser wing of the sphenoid and
inserts on the superior tarsal plate.
What is the innervation of the levator palpebrae
superioris?
The oculomotor nerve
Where does Müller muscle originate and insert?
It originates from the undersurface of the levator palpebrae
superioris and inserts on the superior aspect of the tarsus.
What is the innervation of Müller muscle?
Sympathetic nervous system from the superior cervical
ganglion to the carotid plexus and along the oculomotor
nerve
Describe the margin crease distance.
The distance from the upper eyelid crease to the upper
eyelid margin measured during downgaze
Where should the inferior incision be placed
during upper eyelid blepharoplasty?
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)
What are milia?
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.
Describe the marginal reflex distance-1?
Distance from the center of the pupillary light reflex to the upper eyelid margin during primary gaze
What is the marginal reflex distance-2?
The space between the lower eyelid margin and the
pupillary light reflex during primary gaze (normally ~ 5 mm)
What is the difference between blepharoptosis and
blepharochalasis?
● 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.
What is pseudoptosis?
When the upper eyelid appears to be low as a result of
malposition of the globe or brow rather than eyelid
dysfunction
What is the cause of an undesirable hollowed-out
appearance after cosmetic blepharoplasty?
Excessive resection of orbital fat
What is the anatomical basis for the difference
between the Asian and white upper eyelid?
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.
What is the primary risk of epicanthoplasty in the Asian patient?
Web formation in the medial canthal region
What percentage of Asians demonstrate a “single-eyelid,” and what percentage have an epicanthal fold?
50% and 90%, respectively; the size of the fold is usually
relatively small.
What is the most common form of ptosis?
Acquired aponeurotic or senile ptosis
What is a common clinical sign of acquired
aponeurotic ptosis?
Normal or near normal levator function with an abnormally
elevated upper eyelid crease
What is the most common type of congenital
ptosis?
Congenital myogenic ptosis. Caused by dysgenesis of the
levator palpebrae superioris in which the muscle fibers are
replaced by fibroadipose tissue.
What percentage of congenital ptosis is unilateral?
Approximately 75%
What coexisting ocular condition is present in a
significant number of patients with congenital
ptosis?
Amblyopia
Describe the phenylephrine test for evaluating
ptosis?
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.
Describe the clinical manifestation of myogenic
ptosis secondary to myasthenia gravis.
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.
What surgical technique can be used for treatment of ptosis with poor or absent levator function?
Frontalis sling
What are the clinical manifestations of Marcus Gunn jaw-winking ptosis?
Elevation of a ptotic eyelid during ipsilateral activation of the mandibular division of the trigeminal nerve (chewing,
jaw opening)
