Contributors
Heather Baldwin
Department of Ophthalmology, Rayne Institute, St. Thomas’ Hospital,
London, England, UK
George Brian Bartley
Department of Ophthalmology, Mayo Clinic, Rochester, MN, USA
C. Robert Bernardino
Department of Ophthalmology, Yale Eye Center and
Yale New Haven Hospital, New Haven, CT, USA
Jurij R. Bilyk
Department of Ophthalmology, Jefferson University Hospitals and Thomas Jefferson University Medical College, Philadelphia, PA, USA
Nariman S. Boyle
Assistant Professor of Ophthalmology, Ophthalmic Plastic, Orbital and Reconstructive Surgery, Department of Ophthalmology, State University of New York at Stony Brook, Stony Brook, NY, USA
Adam G. Buchanan
Washington University Eye Center, St. Louis, MO, USA
Eli L. Chang
Department of Ophthalmology, Doheny Eye Institute, Los Angeles, CA,
USA
Shu-Hong Chang
Division of Oculoplastic Surgery, Jules Stein Eye Institute, UCLA School of Medicine, Los Angeles, CA, USA
Adam J. Cohen
Private Practice, Skokie, IL, USA
Vikram D. Durairaj
Associate Professor of Ophthalmology and Otolaryngology, Head and Neck Surgery, Oculoplastic and Orbital Surgery; Fellowship Director, Associate Residency Program Director, Department of Ophthalmology, University of Colorado Denver School of Medicine, Denver, CO, USA
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Jonathan J. Dutton
Department of Ophthalmology, University of North Carolina – Chapel Hill, Chapel Hill, NC, USA
Ian C. Francis
The Ocular Plastics Unit, Prince of Wales Hospital and Sydney Children’s
Hospital, The University of New South Wales, Sydney, Australia
Bartley R. Frueh
Department of Ophthalmology, Kellogg Eye Center,
University of Michigan, Ann Arbor, MI, USA
Mithra O. Gonzalez
Flaum Eye Institute and Department of Ophthalmology, University of
Rochester School of Medicine and Dentistry, Rochester, NY, USA
Milad Hakimbashi
Department of Clinical Ophthalmology, Shiley Eye Center,
University of California – San Diego, La Jolla, CA, USA
Andrew R. Harrison
Department of Ophthalmology and Otolaryngology, University of
Minnesota, Minneapolis, MN, USA
Morris Hartstein
Department of Ophthalmology, St. Louis University School of Medicine,
St. Louis, MO, USA
John T. Harvey
Department of Ophthalmology, McMaster University Medical Centre,
Hamilton, ON, Canada
John B. Holds
Departments of Ophthalmology and Otolaryngology/Head and
Neck Surgery, St. Louis University, St. Louis, MO, USA
Kim Jebodhsingh
Department of Ophthalmology and Vision Sciences, University of Toronto,
Toronto, ON, Canada
Natan D. Kahn
Maine Eye Center, Portland, ME, USA
Robert Kersten
Department of Ophthalmology, University of California-San Francisco,
San Francisco, CA, USA
Don O. Kikkawa
Department of Clinical Ophthalmology, Division of Ophthalmic Plastic and Reconstructive Surgery, Shiley Eye Center, University of California – San Diego, La Jolla, CA, USA
Contributors |
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Jonathan W. Kim
Department of Ophthalmology, Stanford Medical Center, Stanford, CA,
USA
Bobby S. Korn
Department of Clinical Ophthalmology, Shiley Eye Center,
University of California – San Diego, La Jolla, CA, USA
Michael S. Lee
Department of Ophthalmology, Neurology and Neurosurgery,
University of Minnesota, Minneapolis, MN, USA
Ippolit C.A. Matjucha
Neuro-opthalmologist, Comprehensive Surgical Opthalmologist,
Private Practice, Sudbury, MA, USA
Jill Melicher
Fellow Physician, Department of Ophthalmic Plastic and
Reconstructive Surgery, Cincinnati Eye Institute, Cincinnati, OH, USA
Dale R. Meyer
Lions Eye Institute and Department of Ophthalmology,
Albany Medical Center, Albany, NY, USA
Eve E. Moscato
Department of Ophthalmology, University of California-San Francisco
School of Medicine, San Francisco, CA, USA
Ann P. Murchison
Department of Ophthalmology, Jefferson University Hospitals and
Thomas Jefferson University Medical College, Philadelphia, PA, USA
Jefferey A. Nerad
Ophthalmic Plastic and Reconstructive Surgery, Cincinnati Eye Institute; Professor of Ophthalmology, University of Cincinnati, Cincinnati, OH, USA
James Oestreicher
Department of Ophthalmology and Vision Sciences, University of Toronto,
Toronto, Ontario, Canada
Jed Poll
Mount Ogden Eye Center, Ogden, UT, USA
Stuart R. Seiff
Department of Ophthalmology, University of California-San Francisco
School of Medicine, San Francisco, CA, USA
John Shore
Texas Oculoplastic Consultants, Austin, TX, USA
Norm Shorr
Division of Oculoplastic Surgery, Jules Stein Eye Institute,
UCLA School of Medicine, Los Angeles, CA, USA
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David I. Silbert
Armesto Eye Associates, Mechanicsburg, PA, USA
Guy Jonathan Ben Simon
Department of Orbital, Ophthalmic Plastic and Lacrimal Surgery,
The Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel
Alon Skaat
Department of Ophthalmology, The Goldschleger Eye Institute,
Sheba Medical Center, Tel Hashomer, Israel
Chris Thiagarajah
Oculofacial Surgeon, Neuro-ophthalmologist, The Eye Care and Surgery
Center of New Jersey, Westfield, NJ, USA
Jose Luis Tovilla
Department of Ophthalmology, Clínica Florida Satelite, Naucalpán,
Mexico
David A. Weinberg
Concord Eye Care, Concord, NH and Department of Surgery (Ophthalmology), Dartmouth Medical School, Hanover, NH, USA
Geoff Wilcsek
The Ocular Plastics Unit, Prince of Wales Hospital and Sydney Children’s
Hospital, The University of New South Wales, Sydney, Australia
Edward J. Wladis
Department of Ophthalmology, Albany Medical Center, Albany, NY, USA
Edward J. Yen
Department of Ophthalmology, Baylor College of Medicine, Houston,
TX, USA
Renzo A. Zaldivar
Aesthetic Facial and Ocular Plastic Surgery Center, Chapel Hill, NC, USA
Part I
Introduction
Chapter 1
Introduction
Adam J. Cohen and David A. Weinberg
Abstract Blepharoptosis, or drooping of the upper eyelid, is one of the most common surgical
eyelid disorders. The word “ptosis”, which
derives from the Greek ptωsiV (“fall” or “falling”), refers to “abnormal lowering or prolapse of an organ or body part”.1 While one may apply the term “ptosis” to describe any anatomical structure, such as breast or chin ptosis, “ptosis” will be used interchangeably with “blepharoptosis” in this book, strictly referring to the eyelid disorder.
There may be some debate as to what constitutes a ptotic eyelid. One could try to define it quantitatively, based on the margin reflex distance (MRD1), which is the distance from the corneal light reflex to the central upper eyelid margin. Yet, there is a relatively wide variation in eyelid position in the general population, and ethnic and racial differences have been described.2,3 When comparing whites, African Americans, Latinos, and Asians in a similar age bracket, whites displayed the highest mean MRD1 (5.1 mm), while Asians had the lowest (3.8 mm).2 The normal upper eyelid margin rests somewhere between the superior edge of the pupil and the superior limbus, typically around a MRD1 of 4, give or take a millimeter. There would be little argument that a MRD1 of 0 represents a ptotic
A.J. Cohen (*)
Private Practice, The Art of Eyes, Skokie IL, USA e-mail: acohen@theartofeyes.com
eyelid, and a MRD1 of 7 indicates lid retraction. However, where does one draw the line between a “normal” eyelid and a ptotic eyelid? Should ptosis be defined as a MRD1 below 3 mm? 2.5 mm? 2 mm? It is more difficult to define mild ptosis precisely in individuals with symmetric upper eyelids, as opposed to those with asymmetric upper eyelids, i.e., unilateral ptosis. Another way to define ptosis is from a functional standpoint, or qualitatively. Perhaps an eyelid should be considered ptotic if it is low enough to obstruct the visual axis, i.e., below the superior edge of the pupil, since that is the primary functional consequence of ptosis. How low an upper eyelid needs to be in order to obstruct vision depends on the pupil size, and that is affected by ambient lighting conditions, degree of arousal, and systemic or topical drugs, among other factors. By this definition, an upper eyelid would not be functionally ptotic in a patient with a MRD1 of 1.5–2 mm and a pupil size of 3 mm, since the upper edge of the pupil is 1.5 mm above the corneal light reflex.
There is also patient perception. Some individuals may desire wider palpebral fissures that make them appear more alert, even if their vision is not obstructed by the upper eyelid position, while others may wish for the ptotic “bedroom eyes” look of Marilyn Monroe or Marlene Dietrich. Thus, what is “normal” or “abnormal”, and what is desirable vs. undesirable, is in the eyes of the beholder, and so treatment needs to be individualized.
Management of the ptosis patient poses challenges with respect to both diagnosis and
A.J. Cohen and D.A. Weinberg (eds.), Evaluation and Management of Blepharoptosis, |
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DOI 10.1007/978-0-387-92855-5_1, © Springer Science+Business Media, LLC 2011 |
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