7 Pseudoptosis |
65 |
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Fig. 7.7 Right upper eyelid ptosis due to a combination of factors in this anophthalmic socket, including lower eyelid laxity resulting in an inferiorly positioned prosthesis and orbital soft tissue volume deficiency (note the superior sulcus deformity)
behind the intraconal sphere implant, which lifts the sphere implant and displaces fat into the superior sulcus. In general, the underlying orbital or socket abnormality, e.g., soft tissue deficiency or expanded orbital volume due to a blowout fracture, that is responsible for enophthalmos should be addressed before undertaking ptosis surgery. However, in certain cases, the patient may elect instead to only undergo ptosis repair that may simply camouflage the enophthalmos. In such cases, even though the upper eyelid malposition has been repaired, the enophthalmos may still be evident.
When the two eyes are positioned at a different vertical height, eyelid position can be affected. The resultant eyelid position depends on whether the entire orbit is “malpositioned,” i.e., orbital dystopia or craniofacial syndromes, or whether the globe is malpositioned in the orbit, hyperglobus or hypoglobus. Hyperglobus or hypoglobus can produce an appearance of ptosis, ipsilateral to the higher globe. Hyperglobus may result from a space-occupying lesion beneath the globe, either in the orbit or the maxillary sinus, while hypoglobus may be produced by either loss of support beneath the globe (e.g., orbital floor defect or silent sinus syndrome [7]) or a mass above the globe pushing downward on the eye. Obviously, correction of the pseudoptosis in these cases involves addressing the underlying orbital and/or sinus pathology.
The mantra “Define the problem, then solve the problem” provides strong words of wisdom in oculofacial plastic surgery, hence the importance of a thorough examination and careful consideration when deciding on the best course of action when approaching surgical intervention. When a patient presents with a droopy eyelid, one must be certain to first rule out pseudoptosis before moving “full steam” ahead with ptosis surgery.
References
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2.Bartley GB. The differential diagnosis and classification of eyelid retraction. Ophthalmology. 1996; 103(1):168–76.
3.Amato MM, Monheit B, Shore JW. Ptosis surgery. In: Tasman W, Jaeger EA, editors. Duane’s ophthalmology, 2007 edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.
4.Kerty E, Eidal K. Apraxia of eyelid opening: clinical features and therapy. Eur J Ophthalmol. 2006;16(2): 204–8.
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7.Enophthalmos. www.emedicine.medscape.com/article/ 1218658. Accessed 07 Dec 2009.