Oculoplasty, Orbit and Ocular Oncology

Definition

Blepharoptosis, also referred to as ptosis, is defined as an abnormal low-lying upper eyelid margin with the eye in primary gaze.

 

Causes

  • Weakness of the muscle that raises the eyelid.
  • Damage to the nerves that control that muscle.
  • Looseness of the skin of the upper eyelids.

Classification - It is commonly classified as

  • Congenital - Present since birth.
  • Myogenic - Weakness of muscle due to local or systemic cause.
  • Neurogenic - Damage to nerves controlling the muscle.
  • Aponeurotic - Caused by detachment of muscle, seen commonly in older age group, contact lens wearers, excessive rubbing of lids.


Symptoms

  • The primary symptom of ptosis is a visible drooping of the upper eyelid (eye appearing smaller).
  • Frequent eyebrow raising and head tilting can indicate that ptosis is interfering with normal sight.
  • Amblyopia (Lazy eyes) in delayed cases.

Diagnosis

  • Vision testing.
  • Ptosis measurements.
  • Checking extraocular movements.
  • Retinal examination.

Special tests

  • For myasthenia gravis - Icepack test, serum acetyl choline receptor antibody titres, single fiber EMG
  • For Neurogenic cases - MRI brain and orbit in selected cases.

Treatment - Mainly surgical, rarely medical and lid props in selected cases

Surgery is usually very successful in restoring appearance and function. Surgery is done as a day care procedure by an Oculoplasty surgeon. The surgery does not involve any manipulation of the eyeball, hence the vision is not affected by this surgery. However in children if the surgery is delayed it may lead to subnormal vision (Amblyopia).


Patient with bilateral congenital ptosis Note the improvement following surgery.
Medical treatment is useful in patients who have Myasthenia gravis.


Patient with myasthenia gravis. Note the improvement following medical treatment.
Lid crutches are used in patients who have chronic external ophthalmoplegia where surgery is an contraindication.


Patient with Crutch glasses


Special cases

Marcus Gunn Jaw winking - In this condition there is ptosis and abnormal movements of upper lid with mouth opening. Treatment is surgical.

Blepharophimosis syndrome - In this there is ptosis with decrease in the horizontal length of eye with epicanthus inversus and lateral ectropion. Treatment is surgical in form of ptosis surgery with Y- V plasty and lateral canthoplasty.

Ptosis with double elevator palsy - In this condition there is absence of upward movement of eyeball with ptosis. Treatment is squint surgery followed by ptosis surgery.

Various lid malpositions are

  • Ectropion - Out turning of the eyelid margin.
  • Entropion - In turning of the eyelid margin.
  • Lid retraction and lagophthalmos.

Ectropion - Classification

  • Senile - Related to ageing.
  • Cicatricial - Scar formation on the skin due acid/alkali, thermal burns, trauma.
  • Paralytic - Due to facial nerve palsy.
  • Mechanical - Due to cysts, tumors arising from the eyelid skin.

Senile ectropion

Cicatricial ectropion

Entropion - Classification

  • Senile - Related to ageing.
  • Cicatricial - Scar formation on the conjunctiva due to burns, Stevens Johnsons syndrome.
  • Congenital - Maldevelopment of lower lid muscles.
  • Spastic - Active inflammation on the eyelid like stye causes contraction of muscles.

Senile entropion

Causes

  • Horizontal laxity and laxity of medial and lateral canthal laxity.
  • Thinning of tarsal plates.
  • Dehiscence of lower lid retractors.

Symptoms

  • Watering.
  • Irritation and foreign body sensation.
  • Corneal erosions and infections.

Diagnosis

Based on ocular examination and tests done to confirm lower lid laxity and canthal laxity.


Treatment - Primarily Surgical

Surgery is done on day care basis and involves tightening of the lids. These surgeries don’t affect the vision as they are performed on eyelids.





Patient with senile ectropion preop and post op photos




Patient with senile entropion preop and post op photos
Complicated cases require skin grafting or mucous membrane grafting







Patient with thermal burn showing cicatricial ectropion (upper images)
Following skin graft procedure(Lower images)


Lid Retraction and Lagophthalmos

Lid retraction is when the eyelid opening is more than normal
Lagophthalmos is when the eye remains open when closed normally


Causes

  • Thyroid eye disease.
  • Facial Nerve palsy.
  • Drug induced.
  • Central nervous system causes like Parinaud's Syndrome, Tumors of midbrain, Multiple sclerosis.




Symptoms

  • Inability to close eye completely.
  • Redness and eye pain.
  • Burning sensation and foreign body sensation.
  • Corneal ulcer and infection.




Diagnosis

  • Complete eye examination.
  • Measurement of lid retraction and lagophthalmos.
  • Systemic evaluation by physician and neurologist in selected cases.
  • MRI/CT scan in selected cases.

Treatment

Mild cases - Lubricating eye drops and gels, Lid tapping at night.
Severe cases - Gold weight implants, Spacer grafts, Lid tightening procedures.
Treatment of the underlying cause.


Gold implant

Patient with long standing facial palsy showing lid retraction and lagophthalmos

(Preop images)




The same patient with gold implant surgery. (Postop images)




Patient with lower lid spacer graft.

(Preop images)




(Postop images)



The various options are

  • Cosmetic contact lenses.
  • Enucleation/ Evisceration with implants.
  • Dermis fat grafts/ Hydrogel implants in contracted sockets.

Cosmetic contact lens-Used when there is no vision and the eyeball shape and size is almost normal.
However there is always an disadvantage of insertion and removal of the lens.


Enucleation / Evisceration with implant - Most commonly performed surgery for cosmetic rehabilitation of blind eyes.

It involves removal of the coats of eye or sometimes the entire eye along with placement of spherical implant in the orbital cavity.

It can be done in:

  • Disfigured eyes like phthisis bulbi or staphylomas
  • Painful blind eye to get rid of pain.

Implants

  • Non Bio intergrable - Acrylic / Silicon.
  • Biointergrable - Polypropylene / Hydroxyapetite.

Prosthesis - Prosthesis fitting is done 4-6 weeks following the surgery

There are 2 types:
  • Eyeshell.
  • Custom made prosthesis.


Custom made prosthesis are the best option as they give a very good cosmetic match and have a fair amount of motility.



Dermis fat graft/ Hydrogel implants

They are done in cases where there is inadequate socket volume and conjunctival lining.