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Ptosis
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10
Fig.10.1 Ptosis. When assessing ptosis note the brow position, head posture and facial expression
in addition to the lid movement
10.1 Overview (Fig. 10.1)
•
Clinical evaluation
•
Types of ptosis
•
Levator function-based choice of correction
•
Surgical techniques:
– White line advancement, anterior approach,
– Müller’s resection,
– Anterior approach levator aponeurosis reinsertion,
– Silicone frontalis suspension.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
V. Th a l l e r, Eyelid Surgery, https://doi.org/10.1007/978-3-031-31527-5_10
119
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The word ptosis comes from Greek, meaning the act of falling. Ophthalmologists
use the term as shorthand for ‘Blepharoptosis’, namely a dropping upper lid. There
are many different causes of ptosis. Age related ptosis is by far the most common
and is therefore the focus of this chapter. As always, the history of onset is helpful
in diagnosing the type of ptosis, followed by the examination.
10.2 Examination
The following measurements are helpful in choosing the most appropriate ptosis
operation.
10.2.1 Vertical Palpebral Aperture (PA)
This is the distance between the central upper and lower lid margins in primary
gaze (looking straight ahead). It depends on the position of both lids. For greater
accuracy therefore the lid margin to corneal light reflex distances (MRD) are measured for both the upper and the lower lid margins (MRD1 & MRD2 respectively)
(Fig. 10.2). Added together they should equal the PA.
Pseudo ptosis can arise from an overhanging skin fold (Fig. 10.3a) which masks
the true palpaebral aperture.
Vertical ocular misalignment will also cause ‘pseudo ptosis’ of the hypotropic
eye as the lid follows the eye’s position. The pseudoptosis vanishes when the eye
is forced to look straight ahead (Fig. 10.3b). Hypotropia should be addressed by
squint correction before ptosis correction is contemplated. Ten percent of congenital ptosis has an associated superior rectus weakness (as the superior rectus and
levator muscles develop together and share a common innervation).
PA
Fig.10.2 Palpebral aperture (PA) and margin reflex distance (MRD). The PA should equal the
sum of the upper and lower lid MRD
MRD1
MRD2
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a
b
Fig.10.3 Pseudoptosis. a An overhanging skin fold masks the true PA. b The pseudoptosis of a
hypotropic eye disappears when the eye takes up fixation
10.2.2 Levator Function (LF)
This is the distance that the central upper lid margin moves from full downgaze
to full up-gaze while you neutralize any frontalis muscle contribution by pressing
on the brow (Fig. 10.4). Levator function cannot be improved by surgery. Therefore, the LF dictates the choice of operation most likely to work for that patient.
The LF also dictates the degree of post-surgical improvement possible. A patient
with normal levator function is likely to get an excellent (near normal) surgical
outcome. By contrast a patient with poor LF who is successfully corrected for
straight ahead (primary) gaze will still have a degree of ptosis in up-gaze and
‘hang-up’ in downgaze. Levator function is a clinical surrogate measure of muscle
strength.
Normal levator function is an excursion of between 12 and 17 mm. Poor levator
function is 0–4 mm.
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LF
Fig.10.4 Levator Function (LF). LF is the full excursion of the central upper lid margin expressed
in millimetres
10.2.3 Skin Crease (SC) and Skin Fold (SF) (Fig. 10.5)
Most occidental eyelids have a skin crease about 5–10 mm from the lid margin. It
is thought to be caused by the pull of the anterior insertion of the levator aponeurosis into the orbicular fascia. Absence of a skin crease may imply very poor levator
function i.e., no pull on the skin. Oriental lids have a much lower skin crease due
to a lower aponeurosis insertion.
Lax skin above the crease may hang over as a skin fold and hide the true crease.
The skin crease is usually raised in age related, contact lens induced, and postsurgical ptosis, as well as in Horner’s syndrome. Why should this be and what
Fig.10.5 Skin Crease (SC) and Skin Fold (SF). A SF may overhang and mask the true SC
SC
SF
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a
b
c
Fig.10.6 Hang-up in downgaze. a Left upper lid ptosis in primary gaze. b In downgaze the left
ptosis disappears because the lid is prevented from moving down by the dystrophic levator. c In
upgaze the left ptosis worsens because the dystrophic levator cannot lift it as well as the right
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is the common denominator? Perhaps they are all caused by a failure of Müller’s
muscle rather than of the levator aponeurosis?
10.2.4 ‘Hang-Up’ in Downgaze (Fig. 10.6)
A ptosis may seem to reduce, disappear, or even reverse in downgaze. This is
because as well as not contracting normally, an abnormally formed levator muscle
does not relax or stretch as well as the normal contralateral muscle. Such downgaze
‘hang-up’ strongly suggests a congenital ptosis (or previous levator resection).
10.3 Types of Ptosis
10.3.1 Congenital Ptosis
•
Present from birth
•
Reduced levator function (lid margin excursion from full downgaze to full up
gaze).
•
‘Hang-up’ in downgaze (the affected lid does not move as far down as the normal
lid).
•
Sometimes part of a syndrome (e.g., Marcus Gunn jaw wink).
10.3.2 Acquired Ptosis
10.3.2.1 Age Related Ptosis
(synonyms: Involutional, Senile, Aponeurosis disinsertion, Levator dehiscence).
•
The most common.
•
Gradual onset.
•
Normal levator function.
•
Often a raised skin crease.
Note: The term Aponeurotic disinsertion ptosis (above), although frequently used, is
not indicative of the underlying pathology. Rather it derives from the type of surgery
used to correct it i.e., aponeurosis repair or reinsertion.
10.3.2.2 Traumatic Ptosis (Including Post Eye Surgery, Contact Lens
Wear and Birth Trauma)
•
History of causative trauma.
•
Levator function normal unless direct muscle trauma or complete dehiscence.
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10.3.2.3 Myopathic Ptosis (Myaesthenia, Progressive External
Ophthalmoplegia)
•
Gradually deteriorating levator function.
•
Fatiguability.
•
Normal skin crease.
10.3.2.4 Neurological Ptosis (Associated Neurological Signs)
Horner’s Syndrome
•
2 mm of ptosis or less.
•
Normal levator function.
•
Smaller pupil.
•
Ipsilateral anhidrosis and/or skin hyperaemia
Third Cranial Nerve Palsy (Partial or Complete).
•
Poor levator function.
•
Impaired eye movements.
10.4 Choice of Operation
The levator function (range of upper lid movement) dictates the choice of
operation, according to the Table 10.1. But there can be exceptions. An otherwise healthy but severely ‘dehisced’ levator may have reduced levator function
without being weak. A few patients with congenital ptosis have an unusual
levator-extraocular muscle synkinesis that gives them a good levator function measurement, but which does not reflect levator innervation in primary gaze [1]. If this
synkinesis is not spotted the standard surgery will result in an under-correction.
The better the levator function, the better the likely outcome of ptosis surgery.
Near normal levator function should give near normal outcomes. The best that
Table 10.1 Choice of ptosis
correction procedure based
on levator function
Normal 12–17 =<2 Muller’s
Moderate 5–11 Levator
Poor 0–4 Frontalis
Levator function
(mm)
Degree of
ptosis (mm)
>2 Aponeurosis
Preferred
operation
resection
re-insertion
resection
suspension
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a
b
c
Fig.10.7 Post successful ptosis correction with poor levator function (LF). a Left ptosis cor-
rection successful in primary gaze. b In downgaze hang-up is visible (the left upper lid appears
retracted). c In upgaze the ptosis becomes visible
10.5 Operations 127
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can be hoped for with poor levator function is an acceptable lid level in primary
gaze, but under-correction in up-gaze and over correction (hang-up) in downgaze
(Fig. 10.7). The cause of the ptosis must also be considered. A patient with progressive external ophthalmoplegia and a LF of 7 may ultimately do better with
a frontalis suspension than a levator resection as the LF will continue to decline.
Counsel the patients to have realistic expectations regarding what surgery can and
can’t achieve.
10.5 Operations
10.5.1 White Line Advancement (Anterior Approach) Fig. 10.8
Age related ptosis is the commonest ptosis. The easiest and most commonly applicable levator re-insertion operation is the ‘white line advancement’. I strongly
recommend it for all involutional, contact lens related and post periocular surgery
a b
c d
Fig.10.8 White line advancement ptosis correction. a Mark and incise the desired postoperative
skin crease. b Cut through the orbicularis and posterior levator aponeurosis to expose the upper
1/3 of the tarsal plate. c Extend the incision medially and laterally to the full extent of the skin
incision. d Clean the exposed anterior surface of the upper 1/3 of the tarsal plate of any remaining
connective tissue, to ensure firm healing. e Bluntly dissect upwards with a cotton bud to expose the
anterior surface of Müller’s muscle. f Pull the Müller’s muscle downwards and continue the blunt
dissection superiorly until the so called ‘white line’ (folded levator aponeurosis) appears. g Insert a
double armed 6/0 absorbable suture through the white line centrally. h Insert two further white line
sutures similarly and insert both ends of the sutures into the upper 2–3 mm of the exposed tarsal
plate as partial thickness bites. Then pass one of each pair of suture ends out through the upper and
the other through the lower skin edge. i Tie sutures on the skin and complete skin closure with a
suture
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e f
g
h
i
Fig.10.8 (continued)
ptosis, provided that levator function is normal (which it should be in those cases).
White line advancement has two selling points:
1. The first is that mostly it is easy to perform, requiring minimal dissection.
2. The second is that it seems to set the lid at the correct height, as if by magic,
without any per-operative measurement.
It can be performed either via an anterior (skin) or a posterior (conjunctival)
approach. The skin approach is easier to learn and is described below. If required,
it can also be combined with excess skin removal (blepharoplasty) and it causes
no ocular irritation. I acknowledge that many prefer the posterior, conjunctival
approach which avoids a skin incision and works equally well.
Should the white line advancement prove difficult or insufficient it is easy
to convert it to a more formal aponeurosis insertion or levator resection. The
conversion is also described below.
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