Evaluation and Management
of Blepharoptosis
Adam J. Cohen • David A. Weinberg
Editors
Evaluation and
Management
of Blepharoptosis
“Foreword by George Brian Bartley, MD”
Editors |
David A. Weinberg |
Adam J. Cohen |
|
Private Practice |
Concord Eye Care |
The Art of Eyes |
Concord, NH |
Skokie, IL |
and |
USA |
Department of Surgery (Ophthalmology) |
acohen@theartofeyes.com |
Dartmouth Medical School |
|
Hanover, NH |
|
USA |
|
daweinberg@hotmail.com |
ISBN 978-0-387-92854-8 e-ISBN 978-0-387-92855-5 DOI 10.1007/978-0-387-92855-5
Springer New York Dordrecht Heidelberg London
© Springer Science+Business Media, LLC 2011
All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden.
The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights.
While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.
Printed on acid-free paper
Springer is part of Springer Science+Business Media (www.springer.com)
Dedicated to the memory of Bartley R. Frueh, MD –
a superb clinician, scientist, and teacher
Foreword
You are reading this book, presumably, because you want to know more about treating patients with ptotic eyelids (or perhaps that one particularly vexing patient whose droopy eyelid refuses to respond to your normally successful surgical expertise). The good news: any eyelid can be lifted. But more about that later.
First, reflect for a moment on the supreme elegance of the eyelid. Less than an organ but far more than mere tissue, the eyelid is both subtle and sublime. Our eyes can detect, with a quick glance, asymmetries of eyelid height and abnormalities of eyelid contour that measure less than a millimeter. Think of how much nonverbal information can be conveyed by a blink, a wink, a squint, or a glare; eyelids are the primary drivers of facial expression. Twinkling eyes, sad eyes, bedroom eyes, pop-eyes – extraordinarily different subjectively, amazingly similar objectively.
We should pause and ponder, however, if we think that a ptotic eyelid is a ptotic eyelid is a ptotic eyelid. Yes, patients with weak levators walk into our clinics every day, but, given enough time in practice, so also will patients with myasthenia gravis, aneurysms, tumors, chronic progressive external ophthalmoplegia, Marcus Gunn jaw winking, Kearns–Sayre syndrome, blepharophimosis, oculopharyngeal dystrophy, and a host of other unusual but important systemic conditions that we had better not miss. Ptosis keeps odd company and late hours.
When we take a patient with ptosis to the operating room, we must be intimately familiar with the eyelid’s anatomy. It is not intuitive. For example, why does the levator aponeurosis insert on the inferior portion of the tarsal plate rather than to its superior border, where a committee of anatomists probably would design it to terminate? Why are the aponeurotic attachments to the lateral orbital rim so much more robust than their relatively flimsy medial counterparts? Why is Whitnall’s ligament so variable from person to person – and what is it doing there in the first place? Why is our understanding of the relationship between the levator and the superior rectus, and the levator and Müller muscle, so rudimentary? Given that there is so much that we do not know, perhaps we should be surprised by how often we are able to achieve a satisfactory result when we venture forth to treat ptosis.
Unfortunately, surgery for blepharoptosis will likely be one of the last holdouts against the protocolization of medicine. Some practitioners use an
vii
viii |
Foreword |
|
|
anterior approach, levator aponeurotic advancement for virtually every patient – even those with Horner syndrome in which the malfunction is clearly related to Müller muscle. Other operators swear by the posterior approach, Müller muscle – conjunctiva resection, regardless of whether a preoperative phenylephrine test temporarily elevates the eyelid. More subtle technical variations abound. Should one use epinephrine and/or hyaluronidase in the local anesthetic or not? Should one release the septal attachments widely and secure the advanced levator aponeurosis with several sutures or make a small buttonhole in the septum and move the aponeurosis forward with a single stitch? And should those sutures be permanent or absorbable? Should every patient be brought to the upright position intraoperatively to check the eyelid position (such a nuisance…) or can predictable results be achieved by allowing the patient to remain supine throughout the procedure? Should the eyelid crease be purposefully re-created in every case, or will it “find its own level?” Given the overall high rates of success for the various methods of ptosis repair, a randomized clinical trial that was sufficiently powered to demonstrate statistically significant differences when all the above variables are considered would require an untenably large number of enrollees. Surgery for droopy eyelids seems destined to remain as much art as science.
But artists and scientists need humility. As soon as we begin to get confident (or, caveat chirurgeon, begin to get cocky) that ptosis surgery is “routine,” a soap-bubble aponeurosis will chasten us. Or a child with severe unilateral congenital ptosis will be brought to our office by parents who refuse to accept that the eyelid cannot be “fixed” to perfection. (As an aside, in 25 years of discussing the option of extirpating the normal levator and placing bilateral frontalis slings – the Beard operation – I have yet to encounter a patient whose parents embraced the idea.)
Ultimately, for better or for worse, any eyelid can be lifted. We are obliged, therefore, to understand why it is ptotic, what therapeutic options are reasonable, and what consequences may ensue. The treatment of blepharoptosis is a study in balance: between the goal of elevating the eyelid and the need for the eye to be protected, between the relative positions of the upper and lower eyelids which yield the palpebral fissure, and between the eyelid retractors and the eyelid protractors and the muscles of the forehead. Sometimes it takes very little to disrupt the balance. I recall a patient with chronic progressive external ophthalmoplegia whose severe blepharoptosis significantly obscured his vision. Raising his eyelids a single millimeter tipped the balance from comfortable eyes to intolerable exposure, from clear corneas to penlight-visible Rose Bengal staining. The patient and I eventually achieved a visually acceptable state of ophthalmic détente, but it was a sobering lesson for both of us.
Useful lessons abound in this book, which will serve as a valued resource for the thoughtful reader. The collected experience of its esteemed authors represents the state of the art of contemporary ptosis surgery. But…we still have much to learn.
Rochester, MN |
George Brian Bartley, MD |
Preface
Blepharoptosis (ptosis) is a widely prevalent disorder that is encountered by virtually every clinician, whether one is working with an adult or pediatric population. Therefore, it behooves the medical practitioner to be familiar with this condition from the diagnostic standpoint, particularly with respect to identifying a serious underlying disorder, such as an aneurysm, tumor, carotid artery dissection, or myasthenia gravis. Any surgeon who manages ptosis should be well-acquainted with the various surgical approaches to repair since different techniques are often particularly applicable to certain scenarios.
Landmark treatises on ptosis, such as Beard’s Ptosis, are unfortunately out-of-print. Furthermore, while certain aspects of this subject, such as the general technique for external levator resection surgery, may not have changed significantly over the years, there have been major advances in our understanding of the underlying genetics and our ability to identify and classify disorders based on the genetic analysis. This is especially relevant to the various inherited myopathies that are often associated with ptosis, which are reviewed in this book. Admittedly, a comprehensive discussion of myopathic disorders is beyond the scope of this text, and we have condensed that subject to a review of myopathies relevant to the ophthalmologist and ptosis surgeon. As scientific research progresses, we have no doubt that there will be much more to say about pathophysiology and genetics of ptosis in the future.
While many books have been published in the field of oculoplastic surgery, most provide only a limited discussion of blepharoptosis, emphasizing the key points of diagnosis and surgical management. It was our intent to provide a practical reference that offered a 360° view of blepharoptosis – from etiology to management. We begin with a historical perspective, then move on to a review of relevant eyelid anatomy and physiology, how to evaluate the ptosis patient, and then differential diagnosis. Other ocular and periocular disorders may be confused with ptosis, and these are discussed in the chapter on pseudoptosis. After reviewing the various categories of ptosis, classified based on etiology, we cover the management of ptosis, including nonsurgical modalities and the various surgical procedures for ptosis correction, as well as tips regarding anesthesia and analgesia during surgery in order to optimize the surgical experience for both the patient and the surgeon. The significance of patient ethnicity and gender is reviewed. The book
ix
x |
Preface |
|
|
would not be complete without a discussion of surgical complications and the basis for surgery failure and its management. The chapter entitled “Perspective of a Risk Manager” provides a thoughtful analysis of the phy- sician–patient relationship, with suggestions regarding how to establish a favorable rapport with the patient and reduce the likelihood of an unhappy patient, regardless of the outcome of surgery.
This is a multiauthored textbook that is written by experts in the fields of oculofacial plastic surgery and neuro-ophthalmology. This subject matter is relevant to physicians and surgeons in all disciplines that deal with eyelid ptosis, from both a diagnostic and therapeutic perspective. It is our hope that this reference text will be helpful to clinicians in a wide range of specialties and ptosis surgeons, from the novice to the expert.
Skokie, IL |
Adam J. Cohen, MD |
Concord, NH |
David A. Weinberg, MD |