Eyeland Optical Ephrata, 108 N Reading Rd, Ephrata, Pa 17522

Abstract

Meticulous objective examination of a patient with blepharoptosis allows determining the tactics of surgical treatment. It depends on many factors, but primary ones are blepharoptosis etiology, upper eyelid's levator function, and ptosis degree. The interpretation algorithm of objective examination of a patient with blepharoptosis is presented in this commodity.

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Ptosis surgery is challenging even for the most experienced ophthalmologists and plastic surgeons. According to statistics, the prevalence of relapses ranges from 5% to 35% [iv, 12, 15, 16, 23, 24]. In lodge to reduce the frequency of reoperations and improve postoperative symmetry, a thorough preoperative cess of blepharoptosis is necessary.

Exam OF A PATIENT WITH PTOSIS

1. Complaints

Patients usually complain about heaviness in the eyelids, headaches caused by constant tension of the frontal muscle, difficulty in reading, narrowing of the upper half of the visual field, besides as constant fatigue associated with it [13, 14]. An important point in history taking is the ptosis duration. Congenital ptosis manifests itself very early; however, parents often do not notice it. Acquired types of ptosis progress slowly and are chronic in nature. Acute ptosis may be associated with aneurysm of a. communicans posterior, a reactive edema of the upper eyelid – with allergic diseases or acute infections [9, xx]. Ptosis may be the outcome of previous surgery or injury.

It is as well necessary to ask a patient if the caste of ptosis changes during the day, and whether he has double vision. An increase in ptosis in the evening may point myasthenia [18]. Diplopia is registered in patients with paralysis of the third pair of the cranial nerves (CN), as well as with myasthenia [17, eighteen].

2. Degree of ptosis

The deviation betwixt the measured uncovered size of the cornea and its normal size is considered as the degree of ptosis (Fig. 1).

Fig. i. Ptosis degree estimation (adapted from Collin J.R.O., 2006)

Рис. ane. Оценка степени птоза (Collin J.R.O., с измен., 2006)

3. Distance between the upper eyelid edge and the corneal reflex (MRD, marginal reflex distance)

MRD_one is the distance from the corneal lite reflex to the edge of the upper eyelid at the center while looking directly ahead (N is iv–4.5 mm, Fig. ii) [7].

Fig. two. MRD1 and MRD2 measurement (adapted from Collin J.R.O., 2006)

Рис . 2. Оценка MRD _i , MRD _two (Collin J.R.O., с измен ., 2006)

MRD_ii is the distance from the corneal light reflex to the edge of the lower eyelid at the center when looking directly alee (N is v–5.5 mm, Fig. 2). With MRD_two > 5.5 mm, there is either retraction or eversion of the lower eyelid. The patient may accept ptosis of the upper eyelid and normal width of the palpebral fissure due to the low location of the lower eyelid [seven].

MRD_three is the altitude betwixt the corneal light reflex from the eyeball (at the 6 o'clock level of the limbus) and the edge of the upper eyelid at the center while looking up. A prerequisite for this measurement is fixing the eyebrow [vii].

4. Function of the upper eyelid levator

This indicator is estimated using the magnitude of the upper eyelid excursion while changing the position of the look from the bottom upwards with mandatory fixation of the eyebrow/frontal muscle. In the normal condition, the function of the upper eyelid levator should be > 12 mm (Fig. three) [seven, 8, 17].

Fig. 3. Measurement of upper eyelid's levator role (adapted from Collin J.R.O., 2006)

Рис. 3. Оценка функции леватора верхнего века (Collin J.R.O., с измен., 2006)

Classification of the upper eyelid levator part according to Berke [eight] is as follows: ≥thirteen mm is excellent; 8–12 mm is good; v–7 mm is average; and ≤four mm is poor.

5. Margin crease altitude (MCD)

MCD is the altitude from the lower border of the upper eyelid to the palpebral fold. In the normal condition, it ranges from 7–9 mm in men and 8–ten mm in women (Fig. 4) [7, 8, 17]. The absence of a pronounced fold of the upper eyelid indicates the congenital nature of ptosis, while the high location of the fold indicates its aponeurotic nature.

Fig. four. Measurement of distance between the margin and the crease (adapted from Collin J.R.O., 2006)

Рис. 4. Оценка высоты складки верхнего века (Collin J.R.O., с измен., 2006)

6. Expressiveness of the upper eyelid fold: Degree 1 means that it is non expressed, degree 2 ways it is poorly expressed, degree 3 means it is moderately expressed, and caste 4 means it is well expressed (Fig. 5).

Fig. 5. Types of upper eyelid creases (a – one ^st degree, b – 2 ^nd degree, c – 3 ^rd caste, d – 4 ^th degree)

Рис. 5. Выраженность складки верхнего века (a — i-я степень, b — two-я степень, c — 3-я степень, d — 4-я степень)

7. Cess of the upper eyelid fold mobility

To determine the mobility of the upper eyelid fold, the patient is asked to look down and then up while fixing the eyebrow.

8. The width of the palpebral fissure is the altitude between the lower border of the upper eyelid to the top of the lower eyelid at the eye (Fig. 6). In the normal condition, it is 8–10 mm [seven, 8, 17]. To make up one's mind the uniformity of ptosis within the eyelid, we consider it appropriate to measure the width of the palpebral crevice non only at the middle, simply as well in the lateral and medial limbus expanse.
9. The position of the eyelid when looking down: Increased ptosis indicates its aponeurotic nature (Fig. seven, a), and retraction indicates the myogenic nature (Fig. 7, b).

Fig. vi. Measurement of palpebral fissure peak (adapted from Collin J.R.O., 2006)

Рис. 6. Оценка ширины глазной щели (Collin J.R.O., с измен., 2006)

Fig. 7. Aponeurotic ptosis, more pronounced in downgaze (а); Myogenic ptosis, retraction in downgaze (b)

Рис. 7. Апоневротический птоз, усиление птоза при взгляде книзу (а); миогенный птоз, ретракция век при взгляде книзу (b)

10. Phenylephrine test (α ₂ -adrenoceptor agonist)

The examination involves instilling 2.five%-phenylephrine drops and evaluating the MRD_one before and 5 min after the instillation of the drops. It enables to determine the surgical treatment tactics. If, after instilling the drops, the MRD_i index increases by 2–iii mm, the test is considered positive, otherwise information technology is negative (Fig. eight). With a positive test, a conjunctival mullerectomy is recommended, and with a negative test, resection of the levator aponeurosis is recommended [3, 8, 19]. However, recently, an increasing number of studies accept analyzed the feasibility of conjunctival mullerectomy or tarsoconjunctival mullerectomy at a negative phenylephrine test [3, 8].

Fig. 8. Mild ptosis earlier (a) and subsequently (b) phenylephrine instillation

Рис. viii. Частичный птоз до (а) и после (b) закапывания 2,5 % фенилэфрина

11. Bell's miracle

To evaluate Bell's phenomenon, the researcher holds the upper eyelids, while the field of study tries to shut them (Fig. ix). The phenomenon is a protective mechanism, the essence of which is the ability of the eyeball to rotate upward and outward while closing the eyelids; this test is evaluated using the following guidelines:

• pronounced: >²/₃ of the cornea is hidden behind the raised upper eyelid
• moderate: ¹/₃–²/₃ of the cornea is hidden behind the raised upper eyelid
• poor: <^one/₃ of the cornea is subconscious behind the raised upper eyelid

Poorly expressed Bell'due south miracle tin cause exposure keratopathy in the postoperative period [8].

Fig. 9. Poor Bell'due south phenomenon

Рис . ix. Плохо выраженный феномен Белла

12. Ruling out ptosis on the opposite side with unilateral ptosis

According to Hering's law (the law of motor correspondence), synergistic muscles receive the same signal, and in the presence of ptosis, in that location may also be retraction on the other side. Usually, in this situation, the following test is performed: the lowered eyelid is raised, and the position of the eyelid on the contralateral side is observed (Fig. 10) [25].

Fig. ten. Illustration of Hering's police force

Рис . 10. Иллюстрация закона Геринга

13. Cold examination

This test is performed in patients with suspected myasthenia. Information technology is conducted to assess the position of the upper eyelid before and v min afterward applying ice to the upper eyelid [1, 5, 26].

14. Fatigue exam

This test is performed as follows: the patient has to wait up for thirty southward without blinking. The lowering of one or both eyelids too equally the inability to look up indicates myasthenia [1, v, 26].

15. The examination of the ocular surface land

The following tests are included in the basic ophthalmological examination and, to our mind exercise not crave a description of the methodology: Schirmer test, tear break-upwardly time test, staining of the conjunctiva and cornea with vital stains, and corneal sensitivity assessment.

16. Assessment of eyeball motility

Motility impairment can exist observed in myasthenia, lesion of the three^rd pair of CN, besides as in chronic progressive external ophthalmoplegia [17, 18].

17. Evaluation of eyebrow motility

This test is peculiarly relevant when planning surgeries of interruption blazon.

In addition to the above methods, some authors propose to evaluate the angle of the slope of the eyelashes and the force of the levator [two, 3]. An intraoperative assessment of the state of the complex of tarsoorbital fascia and aponeurosis of the upper eyelid levator and Whitnall's ligament is besides crucial. Detail attention should exist paid to their structure, elasticity, and mobility [3].

Ptosis of the upper eyelid can be congenital or acquired. Acquired ptosis in plough can be involutional (aponeurotic), myogenic, neurogenic, or mechanical. The category of pseudoptoses is distinguished and includes retraction of the eyelids and exophthalmos on the contrary side, enophthalmos, prolapse of the lower eyelid, as well as floppy eyelid syndrome [17, 23, 24].

Aponeurotic ptosis

The most common course of aponeurotic ptosis is the involutional type that occurs due to stretching of the upper eyelid levator and weakening or impairment of its attachment to the cartilaginous plate [17, 18, 23]. This type of ptosis is characterized by normal function of the upper eyelid levator and a highly located fold of the upper eyelid (Fig. 11) [17, xviii]. Ptosis tin can be either bilateral or unilateral. Patients with aponeurotic ptosis are non characterized by dumb mobility of the eyeball. Aponeurotic ptosis is often registered after various surgical interventions. Thus, according to the literature, on an average, viii% of the patients who undergo cataract surgery develop aponeurotic ptosis [21, 22, 24]. This may be owing to the damage to the levator aponeurosis in isolation or in combination with the superior rectus muscle in connection with the installation of an eyelid speculum [ten].

Fig. 11. Aponeurotic ptosis

Рис . 11. Апоневротический птоз

Neurogenic ptosis

This category includes ptosis in myasthenia, paralysis of the pair III of CN, and with Horner's syndrome [18].

Ptosis in myasthenia occurs due to a disorder of neuromuscular conduction; therefore, it can be attributed to both myogenic and neurogenic disorders [17, eighteen]. Ptosis tin be unilateral or bilateral and can be asymmetric or expressed equally on both the sides. The severity of ptosis varies from complete to invisible to the patient and others. With ptosis, the extraocular muscles are usually involved in the pathological process. Extraocular muscle involvement is also typical for the pathological process (Fig. 12).

Fig. 12. Neurogenic ptosis: a — in a patient with myasthenia gravis; b — in a patient with Horner's syndrome

Рис. 12. Нейрогенный птоз: а — при миастении; b — при синдроме Горнера

The ocular form of myasthenia, characterized only by damage to the eye muscles, is the almost prevalent of all local forms in adults. Local ocular myasthenia is less common in children than in adults. Isolated ocular symptoms that persist for two years, and sometimes longer, may be the initial manifestations of a generalized form of the illness [26]. A distinctive feature of this type of ptosis is its variability. Ptosis increases in the evening and disappears when exposed to common cold. Additional studies that include analyses of blood serum for the level of autoantibodies to the muscle acetylcholine receptor, proserin test, and electromyographic study are necessary [v].

Paralysis of the 3^rd pair of CN can be a outcome of tumors, vascular lesions, too as inflammatory diseases [eighteen] and is clinically manifested by ptosis, impaired mobility of the eyeball, and its deviation outward (due to the activeness of thou. rectus lateralis and m. obliquus superior not encountering resistance) (Fig. xiii) [17, 23]. Pupillary involvement, manifested by mydriasis, more than oft indicates aneurysm of the a. communicans posterior [26].

Fig. 13. Ptosis in a patient with 3 ^rd cranial nerve palsy

Рис. 13. Птоз при параличе III пары черепно-мозговых нервов

The patient management arroyo may vary. In the presence of mydriasis, magnetic resonance imaging or magnetic resonance angiography must be performed to rule out aneurysm of a. communicans posterior [twenty]. The levator function can be either normal or absent [17]. The latter is much more common. The chief correction method is suspension-type surgery. If the patient has strabismus, it should be adressed first [28].

Ptosis in Horner'southward syndrome develops because of an harm of sympathetic innervation in the tissues of the orbit due to tumors, aneurysms, or inflammatory changes. The main manifestations are ptosis, myosis, enophthalmos, and dyshydrosis of the affected one-half of the face [18, 23]. In this case, ptosis is not pronounced and averages 2–2.5 mm with normal levator function. Several neurological tests, such as cocaine exam, Minor exam, hydroxyamphetamine exam, and Apraclonidine test, are bachelor for the confirmation of Horner's syndrome. The implementation methods are not described in this commodity because the studies are included in the complex of neurological examination.

Myogenic ptosis

The crusade of myogenic ptosis is weakening of the upper eyelid levator [1]. Myogenic ptosis is predominantly congenital [18]. This type of ptosis is caused by the underdevelopment of the upper eyelid levator. Approximately thirty% of the patients with congenital ptosis have a limitation in the upwards mobility of eyeballs. This is mainly considering of the weakening of the ipsilateral superior rectus muscle [17, 18, 28]. Congenital myogenic ptosis is mainly unilateral and is not associated with other anomalies of the confront structure [eighteen]. The levator office can be diverse. The decrease in function is mainly caused by fibrosis of the upper eyelid levator.

We should also mention the connection of congenital ptoses with craniofacial syndromes. The Marcus Gunn syndrome is the most common [17, 18, 23]. The reason for the development of this syndrome is a violation of the connection between the 3^rd pair of CN innervating the upper eyelid levator and the 5^th pair of CN innervating the masticatory muscles. This syndrome is manifested with unilateral ptosis associated with synkinetic retraction of the lowered upper eyelid during stimulation of the masticatory muscles on the ptosis side. The involuntary ascent of the lowered upper eyelid occurs when chewing, opening the mouth or yawning, and moving the lower jaw to the side opposite to that of the ptosis (Fig. fourteen) [eighteen].

Fig. 14. Marcus Gunn Jaw winking miracle

Рис . 14. Синдром Маркуса Гунна

In adults, myogenic ptosis can cause traumatic damage to the upper eyelid levator. However, more often, there is either damage to the muscle aponeurosis, or the three^rd pair of CN. In case of injury of the basic of the orbit, a spiral computed tomography of the orbits is necessary [17].

It is necessary to mention other causes of myogenic ptosis in adults, such every bit oculopharyngeal muscular dystrophy and chronic progressive external ophthalmoplegy [17, 28].

Mechanical ptosis

In most cases, this blazon of ptosis develops due to excess skin hanging over the upper eyelid that causes narrowing of the visual field [17, 18]. Other causes include neoplasms and cicatricial changes in the eyelids (Fig. fifteen) [17, 18, 23]. The principal treatment in this case is elimination of the ptosis cause.

Fig. 15. Dissimilar types of mechanical ptosis

Рис . 15. Различные виды механического птоза

The clear algorithm for examining patients with blepharoptosis, presented within this article, can help determining the correct approach while planning surgical treatment while existence aware of the potential hazards to reduce the chances of hypocorrection, hypercorrection, and relapse.

Near the authors

Vitaly 5. Potyomkin

Pavlov First Petrograd State Medical Academy; Metropolis Multi-Field Hospital No. 2

E-mail: potem@inbox.ru

PhD, Assistant Professor. Department of Ophthalmology; ophthalmologist

Russian Federation, St. petersburg

Elena Five. Goltsman

City Multi-Field Hospital No. 2

Author for correspondence.
Email: ageeva_elena@inbox.ru

Ophthalmologist

Russian federation, Saint Petersburg

Supplementary files

Supplementary Files

Activity

1. Fig. i. Ptosis degree estimation (adapted from Collin J.R.O., 2006)

2. Fig. 2. MRD1 and MRD2 measurement (adjusted from Collin J.R.O., 2006)

3. Fig. 3. Measurement of upper eyelid's levator role (adapted from Collin J.R.O., 2006)

iv. Fig. four. Measurement of distance between the margin and the crease (adjusted from Collin J.R.O., 2006)

5. Fig. 5. Types of upper eyelid creases (a — 1st degree, b — 2nd caste, c — 3rd degree, d — 4th degree)

vi. Fig. 6. Measurement of palpebral cleft height (adjusted from Collin J.R.O., 2006)

7. Fig. 7. Aponeurotic ptosis, more than pronounced in downgaze (а); Myogenic ptosis, retraction in downgaze (b)

eight. Fig. 8. Mild ptosis earlier (a) and subsequently (b) phenylephrine instillation

ix. Fig. 9. Poor Bell's miracle

10. Fig. 10. Illustration of Hering's law

11. Fig. 11. Aponeurotic ptosis

12. Fig. 12. Neurogenic ptosis: a — in a patient with myasthenia gravis; b — in a patient with Horner'due south syndrome

13. Fig. 13. Ptosis in a patient with 3rd cranial nerve palsy

fourteen. Fig. fourteen. Marcus Gunn Jaw winking phenomenon

15. Fig. 15. Different types of mechanical ptosis

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