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Ptosis


It is drooping of upper eyelid in relation to the globe – (Congenital or Acquired)
  1. Causes :  (Acquired)
    1. Neurogenic        
    2. Aponeurotic       
    3. Mechanical          
    4. Myogenic
  1. Neurogenic Ptosis ( Acquired or congenital)
    1. Third nerve palsy                        
    2. Horner syndrome
    3. Marcus Gunn jaw winking syndrome           
    4. Misdirection of third nerve
  2. Aponeurotic: (Senile ptosis)
    Localized dehiscence of aponeurosis disinsertion generalized attenuation or stretching
     
    Treatment.:
    Aponeurosis – strengthening procedure
  3. Mechanical
    1. Scarring
    2. Increased weight due to tumor, edema, dermatochalasia.
      Treatment: Depends upon the cause
  4. Myogenic:
    1. Myasthenia gravis
    2. Myotonic dystrophy
    3. Ocular myopathy
  1. ​Simple congenital ptosis
    1. Due to developmental dystrophy of levator muscle
    2. Lid Lag Absent on downgage
    3. Important- In downgaze the ptotic eyelid is slightly higher than normal eyelid due to poor relaxation*
    4. May be associate with weakness of SR muscle*
    5. Head tilt with chin elevation
Treatment: LPS resection
Severe ptosis : frontalis suspension (sling opleration) Matirals
  1. Fascia lata (Preserred)
  2. Dura
  3. Silicone rods
  1. Blepharophimosis syndrome
    1. AD                                      
    2. Ptosis                  
    3. Telecanthus                        
    4. Epicanthus inversus                      
    5. Lower lid ectropion              
    6. Flat nasal bridge with hypoplasia of superior orbital rim
Treatment:
  • Correction of telecanthus and epicanthus
  1. Marcus – Gums – Winking Syndrome
    1. Occurs due to nuclear or infranuclear connection between 3rd and 4th nerve*
    2. Retraction of ptotic lid with stimulation of ipsilateral pterygoid muscle
    3. Treatment.: Levator disinsertion (excision) combined with sling operation
  1. Levator resection
  1. Blaskovics operation – conjunctive / route
  2. Ever Busch’s- cutaneous route
  3. Frontalis brow suspension- Sling operation (Method of choice – with fascia lata)
b. Aponeurosis strengthening
  1. Entropion (Inversion of eyelid)
    1. 4 main types are:
      1. Involutional-  Affects only lower lid
      2. Cicatricial – Cicatricial pemphigoid, Stevens- Johnson syndrome, trachoma, chemical burns
      3. Congenital- lower eyelid retractors not well- developed
      4. Acute spastic entropion- generally lower lid
    2. Treatment
      1. Involutional Entropion
        1. Cautery                   
        2. Transverse lid everting sutures
        3. Wies procedure        
        4. Fox procedure
        5. Shortening of lower lid retractors – Lester- Jones operation*
        6. Modified wheelers operation – preseptal orbicularis bracing*
      2. Cicatricial Entropion
        1. Epilation                
        2. Surgical correction of deformity
        3. Tarsal fracture       
        4. Mucus membrane grafts
      3. Congenital entropion
        1. Taping
        2. Lid-everting sutures
  2. Ectropion (Outward turning of eyelid )
    1. Main type are
      1. Involutional    
      2. Cicatricial          
      3. Congenital       
      4. Paralytic
      5. Involutional Ectropion
        • Affects only lower lid        
        • Treatment
        1. Medical ectropion
          • Ziegler cautery punctures
          • Medial conjunctivoplasty
          • Lazy – T procedure
        2. Extensive ectropion*
          • Bick procedure*
          • Modified Kuhnt-Szymanowski procedure
      6. Cicatricial Ectropion
        1. Due to tumor, trauma , burns
        2. Treatment.: Excision of scar with Z- plasty transpositions flaps, of free skin grafts
      7. Congenital Ectropion
        1. Associated with blepharophimosis syndrome
        2. Affects lower lid
        3. Treatment.: Replacement of vertical skin defect with full- thickness skin graft
      8. Paralytic ectropion : - Due to facial nerve palsy,
Treatment
  1. Temporary Treatment
  1. Artificial tears, ointment and strapping of lids during night
  2. If very poor Bell’s phenomenon then do tarsorrhaphy
  1. Permanent Treatment
  1. Medial canthoplasty
  2. Graded levator recession
  3. Prosthetic devices – silicone rings




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