- •Foreword
- •Preface
- •Acknowledgments
- •Contents
- •Contributors
- •References
- •References
- •Introduction
- •Eyelid Anatomy
- •Eyelid Skin
- •The Orbicularis Muscle
- •The Orbital Septum
- •The Preaponeurotic Fat Pockets
- •The Major Eyelid Retractors
- •The Sympathetic Eyelid Retractors
- •The Tarsal Plates
- •The Canthal Tendons
- •The Conjunctiva
- •Nerves to the Eyelids
- •Vascular Supply to the Eyelids
- •Upper Eyelid Physiology
- •References
- •Introduction
- •Ocular Surface Disease
- •Medications
- •Prior Ocular and Periocular Surgery
- •Contact Lens Use
- •Miscellaneous Conditions
- •Congenital Ptosis
- •Conclusion
- •References
- •Recognise the Ptosis!
- •Unsafe Ptosis
- •Safe Ptosis
- •Distinguishing Safe Ptosis from Unsafe Ptosis
- •Lifting the Ptotic Lid
- •Contralateral Lid Retraction
- •Proptosis and Enophthalmos
- •Frontalis Overaction
- •The Dry Eye Patient
- •Definitive Examination of the Ptosis
- •Special Diagnostic Tests for Ptosis
- •References
- •Introduction
- •History
- •Physical Exam
- •Determination of Procedure
- •Blood Thinners
- •Patient Expectations
- •When Not to Operate
- •References
- •References
- •Pathogenesis
- •Myogenic Causes
- •Aponeurotic Causes
- •Mechanical Causes
- •Neurogenic Causes
- •Pseudoptosis
- •Examination
- •Preoperative Considerations
- •Surgical Repair
- •Müllerectomy
- •Levator Resection
- •Frontalis Suspension
- •Conclusions
- •References
- •Introduction
- •Background
- •Etiology
- •Clinical Findings
- •Ophthalmic Exam
- •Treatment
- •Conclusions
- •References
- •Introduction
- •Congenital Myogenic Ptosis
- •Acquired Myogenic Ptosis
- •Evaluation of the Patient
- •Treatment
- •References
- •Overview
- •Diagnosis: Clinical
- •Diagnosis: Testing
- •Medical Therapy
- •Surgical Therapy
- •References
- •Introduction
- •Third Nerve (Oculomotor) Palsy
- •Diagnosis
- •Localization of a Third Nerve Palsy
- •Common Etiologies for Third Nerve Palsy
- •Horner Syndrome
- •Diagnosis
- •Pharmacologic Evaluation
- •Localization of Horner Syndrome
- •Radiographic Evaluation
- •Horner Syndrome in Children
- •Treatment
- •References
- •Introduction
- •Iatrogenic Causes of Ptosis
- •Ptosis Postintraocular Surgery
- •Ptosis Posteyelid and Adnexal Procedures
- •Contact Lens Wear
- •Ptosis Following Systemic Interventions
- •Birth Trauma
- •Blunt Trauma
- •Lacerating Trauma
- •Traumatic Ptosis Secondary to Restrictive Scarring
- •Traumatic Ptosis Following Facial Fractures
- •Neurogenic Ptosis Secondary to Trauma
- •Traumatic Superior Orbital Fissure Syndrome
- •Blepharoptosis Secondary to Traumatic Third Nerve Palsy
- •Isolated Neurogenic Ptosis
- •Traumatic “Ptosis” Secondary to Facial Synkinesis
- •References
- •Etiology
- •Evaluation
- •Solutions
- •Conclusion
- •References
- •Introduction
- •Pathophysiology
- •Clinical Evaluation
- •Surgical Management
- •Minimal Lash Ptosis
- •Moderate to Severe Lash Ptosis
- •Conclusion
- •References
- •Introduction
- •Mechanical Measures
- •Lid Crutches
- •Eyelid Taping
- •Glues
- •Apraclonidine
- •Medical Measures: Botulinum Toxin
- •References
- •Introduction
- •Procedure
- •Conclusion
- •Suggested Reading
- •Introduction
- •Principle of the Procedure
- •Methodology of the Procedure
- •References
- •Technique [5]
- •References
- •Introduction
- •Surgical Technique
- •Preservation of the Conjunctiva
- •Discussion
- •References
- •History
- •Mechanism of Action
- •Indications
- •Procedure
- •Description of the Procedure
- •Complications
- •Discussion
- •References
- •Indications
- •Techniques
- •Lamellar Technique
- •En Bloc Technique
- •Challenges and Solutions
- •Pearls
- •References
- •Indications
- •Autologous Tissue for Frontalis Suspension
- •Autogenous Fascia Lata
- •Harvesting Fascia Lata
- •Temporalis Fascia
- •Harvesting Deep Temporalis Fascia
- •Palmaris Longus Tendon
- •Harvesting Palmaris Longus Tendon
- •Frontalis Muscle Flap Advancement
- •Allografts for Frontalis Suspension
- •Preserved Fascia Lata
- •Other Processed Tissues
- •Synthetic Materials for Frontalis Suspension
- •Techniques for Frontalis Suspension
- •Double Triangle or Rhomboid Frontalis Sling
- •Single Pentagonal Frontalis Sling
- •References
- •The Transition to Office-Based Surgery
- •Reasons to Transition
- •Surgical Space and Equipment
- •State Regulations
- •Procedure Selection
- •Patient Selection
- •Evaluating Patients at Risk for Anxiety
- •Nonmedical Prevention of Anxiety
- •Medical Prevention of Anxiety
- •Postoperative Nausea and Vomiting
- •Anesthesia for Surgery
- •Topical Anesthetics
- •Injectable Anesthetics
- •Postoperative Pain Control
- •Conclusion
- •References
- •References
- •References
- •Etiology and Evaluation
- •Treatment
- •Surgical Technique
- •Aporneurotic Ptosis Repair
- •Frontalis Sling
- •Complications
- •Summary
- •Tarsal Switch
- •Severe Horizontal Eyelid Laxity
- •Inadequate Tarsus
- •Neurofibromatosis
- •References
- •Involutional/Aponeurotic ptosis
- •Levator Advancement/Plication
- •Congenital Myogenic Ptosis
- •Frontalis Suspension
- •Levator Resection
- •Maximal Levator Resection
- •Whitnall’s Sling
- •Summary
- •References
- •Introduction
- •Preoperative Factors
- •Intraoperative Factors
- •Postoperative Factors
- •Surgical Approach to Ptosis Reoperation
- •Summary
- •References
- •Entropion
- •Symblepharon
- •Ectropion
- •Contour Deformity
- •Lagophthalmos
- •Eyelid Fold and Crease
- •Conjunctival Prolapse
- •Hemorrhage/Hematoma
- •Infection
- •Conclusion
- •References
- •Twelve Steps to a Successful Surgical Encounter
- •Index
12 Neurogenic Blepharoptosis |
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Table 12.4 Surgical options for neurogenic ptosis |
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Procedure |
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Frontalis sling |
Levator advancement/resection |
Müllerectomy |
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Third nerve palsy |
Horner syndrome |
Horner syndrome |
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Apraxia of eyelid opening |
Negative response to phenylephrine |
Positive response to phenylephrine |
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Ptosis >2 mm |
Ptosis <2 mm |
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Dermatochalasis |
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Previous levator surgery |
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vanillylmandelic acid (VMA) and homovanillic acid (HVA) (24-h collection) are obtained to look for elevated catecholamine levels [20]. A serologic laboratory panel is rarely diagnostic but can be used to guide further testing (liver function tests, CBC, LDH, ferritin levels). Chest and abdominal imaging with CT scans is the mainstay for evaluating the thoracic and retroperitoneal cavities. MRI is recommended for evaluating the head, neck, and paraspinal regions. Finally, a methyliodobenzyguanadine (MIBG) scan is a specific method for documenting skull and skeletal metastases in neuroblastoma since this agent accumulates in catecholaminergic cells.
be adequately explained on an anatomic basis. The clinical response of Müller’s muscle to phenylephrine suggests that the muscle fibers can be pharmacologically activated by its adrenergic receptors. However, the surgical success of Müllerectomy in Horner syndrome patients is somewhat surprising since the denervated muscle is atonic. Glatt and Putterman postulated that the mechanism of action of Müllerectomy in these cases is independent of its effect on Müller’s muscle, and likely related to a shortening or augmentation of the levator aponeurosis [21]. In any case, the surgical approach for correcting eyelid ptosis in a Horner syndrome patient is based on the response to topical phenylephrine and other preoperative surgical factors (see Table 12.4).
Treatment
As with other causes of neurogenic ptosis, the strategy for treating Horner syndrome is aimed at correcting the underlying etiology. However, even with successful treatment of the primary disease, it is not uncommon for the blepharoptosis to persist, particularly for patients with longstanding Horner syndrome. Since levator excursion is normal in Horner syndrome, the blepharoptosis can be treated with either an anterior approach (i.e., levator surgery) or posterior approach (i.e., Müllerectomy) ptosis repair. Determining a patient’s candidacy for posterior approach ptosis repair is based on the patient’s response to topical phenylephrine; if eyelid elevation is adequate following the instillation of 2.5% phenylephrine, Müllerectomy can be recommended. The prognostic effect of topical phenylephrine in Horner syndrome patients cannot
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