Grand Rounds Conference Reema Syed, MBBS University of
Louisville Department of Ophthalmology and Visual Sciences October
3, 2014 Slide 2 Subjective CC: droopy right eyelid HPI: 7 month old
male referred to Oculoplastics clinic by Peds Ophthalmology for
evaluation of right upper lid ptosis. Ptosis was present since
birth, however, child was noted to have a fixation preference for
OS at his pediatric ophthalmologist recently. Patching OS was
started for 1 hour/day Slide 3 History POH: ptosis OD PMH: full
term, uncomplicated vaginal delivery, no birth trauma Eye Meds:
None, patching OS 1hr/day Meds: none Allergies: None Family Hx:
lazy eye (father) Slide 4 Objective ODOS VA (sc):CS-UMCSM Pupils: 4
to 2 mm 4 to 2 mm No anisocoria or RAPD IOP:15 15 EOM: Full Full
orthophoric in primary gaze Cycloplegic refraction: +1.00 +1.00 x90
+1.00 +1.00 x90 +1.00 +1.00 x90 +1.00 +1.00 x90 Slide 5 Slide 6
Objective PLE: ODOS Lidsupper lid position wnl does not change with
feeding No palpable masses Eyelid creaseminimalnormal Palpebral
fissure5 mm9 mm Marginal reflex1 mm4 mm distance - 1 Levator
function2-4 mm10-12 mm Slide 7 Objective Conjunctiva/ScleraNormal
OU CorneaClear OU Anterior Chamberformed OU IrisNormal OU No
heterochromia LensClear OU VitreousNormal OU ONc/d 0.2, sharp and
pink OU MVPNormal OU Slide 8 Assessment 7 month old M with upper
lid ptosis and poor levator function OD, without any other ocular
or systemic anomalies who has recently developed amblyopia OD 7
month old M with upper lid ptosis and poor levator function OD,
without any other ocular or systemic anomalies who has recently
developed amblyopia OD DDx: DDx: - Isolated unilateral congenital
ptosis - Marcus Gunn jaw winking syndrome - Blepharophimosis
syndrome - Congenital third nerve palsy - Congenital Horner's
syndrome - Congenital fibrosis of extra-ocular muscles - Upper
eyelid mass (neurofibroma, dermoid cyst) - Pseudo-ptosis Slide 9
Congenital Ptosis Caused by maldevelopment of levator palpebrae
superioris due to abnormal innervation Caused by maldevelopment of
levator palpebrae superioris due to abnormal innervation normal
muscle tissue replaced by fibrous and fatty tissue normal muscle
tissue replaced by fibrous and fatty tissue Characterized by
decreased levator function, lid lag, lagophthalmos Characterized by
decreased levator function, lid lag, lagophthalmos Slide 10 - May
be sporadic or familial (gene unknown) - Strabismus 30%,
anisometropia 12%, amblyopia 20% - 2/3 unilateral, 1/3 bilateral
may be asymmetric - Surgery usually delayed until 3-5 yrs of age
unless: - Deprivational or anisometropic amblyopia - Ocular
torticollis Slide 11 Amount of upper lid excursionLevator function
11 mm or moreNormal 8-10 mmGood 5-7 mmFair 4 mm or lessPoor Slide
12 Treatment Options - Levator resection: - used when levator
function is good - amount of upper eyelid excursion used to
determine the amount of muscle to be resected * Smith B, Della
Rocca R, Nesi F. Ophthalmic Plastic and Reconstructive Surgery. Vol
1. Philadelphia: CV Mosby, 1987:Fig. 30-27 Slide 13 -Frontalis
suspension: -used when absent or poor levator function -most
commonly used for congenital ptosis -eyelid suspended directly from
the frontalis so that movement of the brow can be used to elevate
the eyelid *Amato M, Monheit B and Shore J. Ptosis surgery. Volume
5, Chapter 78, fig 13 Slide 14 Choice of sling material
AdvantagesDisadvantages Autogenous Fascia Lata- Gold standard -
Excellent tensile strength - Best long-term results - Recurrence
unlikely - Need for another surgical site - increased risk of
infection - Minimum age 3 yrs Allogenic Fascia Lata- any age -
Second donor site not required - Small chance of rejection -
transmission of infection from donor to recipient Supramid- any age
- Second donor site not required - High chance of recurrence due to
degradation of sling material Silicone- Not associated with
recurrence - Can be adjusted intra and post-operatively to adjust
lid margin height over time Slide 15 Complications Under/over
correction Under/over correction Asymmetric eyelid contour
Asymmetric eyelid contour Scarring Scarring Wound dehiscence Wound
dehiscence Eyelid crease asymmetry Eyelid crease asymmetry
Lagophthalmos with exposure keratitis Lagophthalmos with exposure
keratitis Slide 16 Back to our patient Underwent silicone rod
frontalis suspension OD Underwent silicone rod frontalis suspension
OD 1 week post-op Slide 17 Retrospective chart review of 4 patients
with ocular torticollis due to bilateral congenital or acquired
ptosis who underwent surgical correction pre and post operative
systemic symptoms in 1 adult and developmental milestones in 3
children are described Adult patient: 62 yr M with history of
severe bilateral ptosis for 10 yrs presented to his PCP with
debilitating upper back pain for 3 yrs. Pain persisted despite
multiple referrals and therapies. Abnormal head posture due to
ptosis found on ophthalmic exam. Pain began to resolve within a
week of surgical correction of ptosis Children: 12m, 10m, 5m olds
with bilateral ptosis and development of head-tilt, chin up
position. No amblyopia but severe delays in gross motor development
without delay in any other milestones. Caught-up with motor
milestones within a few months of corrective surgery Slide 18
References BCSC Orbit, Eyelids and Lacrimal System BCSC Orbit,
Eyelids and Lacrimal System BCSC Pediatric Ophthalmology and
Strabismus BCSC Pediatric Ophthalmology and Strabismus Smith B,
Della Rocca R, Nesi F. Ophthalmic Plastic and Reconstructive
Surgery Smith B, Della Rocca R, Nesi F. Ophthalmic Plastic and
Reconstructive Surgery Amato M, Monheit B and Shore J. Ptosis
surgery Amato M, Monheit B and Shore J. Ptosis surgery Loff HJ et
al. transconjunctival frontalis suspension: a clinical evaluation.
Ophthal Plast Reconstr Surg. 1999; 15(5): 349-354. Loff HJ et al.
transconjunctival frontalis suspension: a clinical evaluation.
Ophthal Plast Reconstr Surg. 1999; 15(5): 349-354. Baroody M et al.
Advances in the diagnosis and treatment of ptosis. Curr Opin
Ophthal. 2005; 16(6):351-355 Baroody M et al. Advances in the
diagnosis and treatment of ptosis. Curr Opin Ophthal. 2005;
16(6):351-355 Lee M, et al. Frontalis Sling Operation using
silicone rod compared with preserved fascia lata for cogenital
ptosis. Ophthalmology 2009; 116(1) 123-129. Lee M, et al. Frontalis
Sling Operation using silicone rod compared with preserved fascia
lata for cogenital ptosis. Ophthalmology 2009; 116(1) 123-129.
Slide 19 Thank you
