Ptosis (pronounced to'sis) simply means droopy eyelid. It is one of the most common eyelid problems. The lid may droop slightly, or cover the entire pupil. Ptosis can restrict and even block normal vision. It can be present in children and adults, and is usually treated with surgery.
When ptosis is present at birth, it is called "congenital ptosis." For moderate to severe cases, treatment is necessary to allow for normal vision development. If congenital ptosis is not corrected, amblyopia (lazy eye) may develop, which, if left untreated, can lead to permanent loss of vision.
Congenital ptosis is often caused by poor development of the levator muscle (the muscle that lifts the eyelid). It is usually an isolated problem, but may also be associated with eyelid tumors, muscular diseases, strabismus (eye movement abnormalities), neurological disease, or refractive error (need for eyeglasses).
Congenital ptosis is treated differently depending on severity and the strength of the levator muscle. If the ptosis is severe, the levator muscle is tightened when the levator muscle's strength is fair to good. When the levator muscle is extremely weak, the eyelid can be suspended from under the eyebrow (frontalis suspension) so that the forehead lifting muscles can do the lifting. If the ptosis is mild to moderate, surgery is usually not needed early in life, and may be delayed until the child is older.
Ideally, ptosis correction is best performed with the patient awake with mild sedation and local anesthesia (monitored anesthesia care), as apposed to being asleep (general anesthesia). This is because real-time adjustments can be made after asking the patient to open his eyes and assessing the eyelid height. Otherwise, post-operative adjustments require another trip to the operating room. If the ptosis is mild enough, delaying surgery until the patient is old enough to have it under monitored anesthesia care is often recommended.
Thursday, October 8, 2009
How Are Ectroprion and Entroprion of the Eyelid Different and How Are They Treated? How Are Ectroprion and Entroprion of the Eyelid Different and How Are They Treated?
Ectropion refers to an out-turned lower eyelid and can occur for three different reasons. The most common is age-related involutional ectropion, where there is excessive laxity in the bottom lid. The next most common type is paralytic ectropion, where there is partial or complete paralysis of the facial muscles, such as after a stroke or from Bell's palsy. The third type is cicatrial (scarring) ectropion, caused by trauma related scarring or skin diseases with tightening of the skin. Symptoms include tearing, mattering of the lashes, irritation, and erythema (redness) of the eye's bottom lid.
Involutional (age-related) and paralytic ectropion are repaired by tightening. A small incision is made in the outer corner of the bottom lid, which is tightened and reattached just inside the lateral orbital rim -- like a "nip and tuck." This is performed as a same day surgery with light sedation and local anesthesia. Cicatricial ectropion is a bit more complicated to repair. Sometimes, a skin graft is required.
Entropion refers to an in-turned bottom lid, where the lashes are rubbing against the eyeball. This can be quite irritating to a patient, and, if left untreated, can cause permanent damage to the cornea and loss of vision. Involutional (age related) is the most common type of entropion. This is caused by vertical laxity in the lower lid retractors (muscles that pull the lower lid down and back) combined with horizontal laxity in within the lower lid.
Symptoms include chronic redness, irritation, tearing, foreign body sensation, and loss of vision.
Entropion repair is performed as a same-day surgery with light sedation and local anesthesia. Treatment is aimed at tightening the lower lid retractor muscles through a small incision just beneath the lower lashes. An additional lower lid tightening procedure is performed through a small incision at the outer corner of the eyelids. The incisions are closed with fine absorbable sutures.
Ectropion refers to an out-turned lower lid. Ectropion can occur for three different reasons. The most common is age-related involutional ectropion, where there is excessive laxity in the lower lid. The next most common type is paralytic ectropion, where there is partial or complete paralysis of the facial muscles, such as after a stroke or from Bell's palsy. The third type is cicatrial (scarring) ectropion, caused by trauma related scarring or skin diseases with tightening of the skin.
Symptoms include: tearing, mattering of the lashes, irritation, and erythema (redness) of the lower lid
Involutional (age-related) and paralytic ectropion are repaired with a lower lid tightening procedure. A small incision is made in the outer corner of the lower eyelid, and the lower eyelid is tightened and reattached just inside the lateral orbital rim. Think of it as a "nip and tuck" for the lower eyelid. This is performed as a same day surgery with light sedation and local anesthesia. Cicatricial ectropion is a bit more complicated to repair. Sometimes, a skin graft is required.
Entropion refers to an in-turned lower eyelid, where the lashes are rubbing against the eyeball. This can be quite irritating to a patient, and if left untreated, can cause permanent damage to the cornea and loss of vision. Involutional (age related) is the most common type of entropion. This is caused by vertical laxity in the lower eyelid retractors (muscles that pull the lower lid down and back) combined with horizontal laxity in within the lower eyelid.
Symptoms include, chronic redness, irritation, tearing, foreign body sensation, and loss of vision.
Entropion repair is performed as a same-day surgery with light sedation and local anesthesia. Treatment is aimed at tightening the lower lid retractor muscles through a small incision just beneath the lower lashes. An additional lower lid tightening procedure is performed through a small incision at the outer corner of the eyelids. The incisions are closed with fine absorbable sutures.
What is Thyroid-Associated Orbitopathy (Graves Disease) And How is it Treated?
Thyroid-associated orbitopathy (TAO), also known as thyroid eye disease (or Graves' eye disease) is the most common specific inflammatory condition affecting the orbit (eye socket) and periorbital tissues. The management of TAO involves both surgical and medical components.
TAO is associated with Graves' thyroid disease, and can present at any time in the course of the disease, whether the patient is in a euthyroid (normal thyroid), hypothyroid (underactive), or hyperthyroid (overactive) state.
The cause of TAO is unknown. In theory, the immune system promotes inflammation directed at the structures around the eye. Extraocular muscles (muscles that move the eye) are the primary site of inflammation. Orbital fat and eyelid muscles are also commonly involved.
Demographically, TAO is most prevalent among middle-aged Caucasian women, though it occurs in all races. It is particularly rare among Asians. Though less often affected, men tend to have a more severe course than women.
There are two phases of thyroid-associated orbitopathy. The active, inflammatory phase may last from 6 months to 5 years. Signs and symptoms change or progress over weeks to months. The non-active, post-inflammatory phase begins once the signs and symptoms have remained stable for at least 6 months.
Signs and symptoms of active thyroid-associated orbitopathy include: eyelid retraction (particularly lateral flare) causing "thyroid stare", dry eye syndrome, periorbital edema (swelling), conjunctival swelling (boggy, wet eyes), restrictive strabismus with double vision, proptosis (bulging eyes), and vision loss due to compressive optic neuropathy (damage to the optic nerve - the optic nerve connects the eye to the brain).
The active phase of thyroid associated managed by corneal lubrication (artifical tears), oral corticosteriods (prednisone), corticosteriod injections to the orbit, orbital radiation, and, in the rare case of optic nerve compression, orbital decompression.
Generally, surgical management is reserved for the post-inflammatory or non-active phase of the disease, except when vision-threatening disorders (e.g., optic neuropathy or severe corneal exposure) are present.
The signs and symptoms of the non-active phase include eyelid retraction, exposure keratopathy, restrictive strabismus (tightness and pulling sensations when moving the eyes causing double vision), proptosis and compressive optic neuropathy with vision loss.
If mild to moderate, management may only require artificial tears. If more severe, then surgery is usually required. Surgical management of TAO must follow a staged sequence of procedures:
1. Orbital Decompression
Orbital decompression, if required, is performed first in the surgical staging of TAO. There are several indications for orbital decompression in patients with TAO: compressive optic neuropathy, exposure keratopathy due to proptosis, orbital pain, elevated intraocular pressure, and cosmetic deformity.
Orbital decompression in TAO is achieved by removal of orbital bony wall and/or orbital fat. Removing portions of one or more of the bony walls of the orbit expands the volume available to the orbital fat and extraocular muscles.
Typically, a balanced orbital decompression is performed, which involves removal of the lateral orbital wall (outside wall) and medial orbital wall (inside wall), along with orbital fat. An orbital surgeon removes the lateral wall through a superior eyelid crease incision, and an otolarygologist removes the medial wall by an endoscopic approach through the nose. Usually, both procedures are during the same surgery. This is a major operation requiring general anesthesia and usually an overnight hospital stay.
2. Strabismus Correction
The goal of surgical therapy is not to eliminate double vision entirely, but, rather, to move the region of single binocular vision into a more functional area (straight ahead and down). Because of the unpredictable nature of restricted extraocular muscles, surgery is usually performed with adjustable sutures. Adjustable sutures allow the alignment of the eyes to be fine-tuned in the postoperative period -- when the patient is awake and alert, thus improving the final surgical outcome.
3. Correction of Eyelid Retraction
Upper lid retraction can cause dry-eye symptoms and corneal exposure, and may even induce a corneal ulcer due to inadequate lid closure. It also contributes significantly to cosmetic disfigurement. Due to the tendency for spontaneous improvement, surgery for isolated upper lid retraction is usually performed only after at least one year of observation.
Eyelid retraction surgery is performed after decompressive and strabismus surgeries have been completed and the lid position has been stable for six months or more.
Upper lid retraction is corrected with a levator recession operation. The levator muscle (muscle that lifts the eyelid) is lengthened, thus allowing the upper lid to cover more of the eye. One can think of this operation as the opposite of a ptosis (drooping eyelid) repair.
Lower eyelid retraction is a common problem in TAO' patients. Patients with lower eyelid retraction complain of tearing, dryness, and foreign-body sensation. They frequently have evidence of exposure keratopathy. The most commonly used method of elevating the lid involves placing a tissue spacer within the back surface of the eyelid, thus effectively elongating the lower lid.
TAO is associated with Graves' thyroid disease, and can present at any time in the course of the disease, whether the patient is in a euthyroid (normal thyroid), hypothyroid (underactive), or hyperthyroid (overactive) state.
The cause of TAO is unknown. In theory, the immune system promotes inflammation directed at the structures around the eye. Extraocular muscles (muscles that move the eye) are the primary site of inflammation. Orbital fat and eyelid muscles are also commonly involved.
Demographically, TAO is most prevalent among middle-aged Caucasian women, though it occurs in all races. It is particularly rare among Asians. Though less often affected, men tend to have a more severe course than women.
There are two phases of thyroid-associated orbitopathy. The active, inflammatory phase may last from 6 months to 5 years. Signs and symptoms change or progress over weeks to months. The non-active, post-inflammatory phase begins once the signs and symptoms have remained stable for at least 6 months.
Signs and symptoms of active thyroid-associated orbitopathy include: eyelid retraction (particularly lateral flare) causing "thyroid stare", dry eye syndrome, periorbital edema (swelling), conjunctival swelling (boggy, wet eyes), restrictive strabismus with double vision, proptosis (bulging eyes), and vision loss due to compressive optic neuropathy (damage to the optic nerve - the optic nerve connects the eye to the brain).
The active phase of thyroid associated managed by corneal lubrication (artifical tears), oral corticosteriods (prednisone), corticosteriod injections to the orbit, orbital radiation, and, in the rare case of optic nerve compression, orbital decompression.
Generally, surgical management is reserved for the post-inflammatory or non-active phase of the disease, except when vision-threatening disorders (e.g., optic neuropathy or severe corneal exposure) are present.
The signs and symptoms of the non-active phase include eyelid retraction, exposure keratopathy, restrictive strabismus (tightness and pulling sensations when moving the eyes causing double vision), proptosis and compressive optic neuropathy with vision loss.
If mild to moderate, management may only require artificial tears. If more severe, then surgery is usually required. Surgical management of TAO must follow a staged sequence of procedures:
- Orbital Decompression
- Strabismus Correction
- Correction of Eyelid Retraction
1. Orbital Decompression
Orbital decompression, if required, is performed first in the surgical staging of TAO. There are several indications for orbital decompression in patients with TAO: compressive optic neuropathy, exposure keratopathy due to proptosis, orbital pain, elevated intraocular pressure, and cosmetic deformity.
Orbital decompression in TAO is achieved by removal of orbital bony wall and/or orbital fat. Removing portions of one or more of the bony walls of the orbit expands the volume available to the orbital fat and extraocular muscles.
Typically, a balanced orbital decompression is performed, which involves removal of the lateral orbital wall (outside wall) and medial orbital wall (inside wall), along with orbital fat. An orbital surgeon removes the lateral wall through a superior eyelid crease incision, and an otolarygologist removes the medial wall by an endoscopic approach through the nose. Usually, both procedures are during the same surgery. This is a major operation requiring general anesthesia and usually an overnight hospital stay.
2. Strabismus Correction
The goal of surgical therapy is not to eliminate double vision entirely, but, rather, to move the region of single binocular vision into a more functional area (straight ahead and down). Because of the unpredictable nature of restricted extraocular muscles, surgery is usually performed with adjustable sutures. Adjustable sutures allow the alignment of the eyes to be fine-tuned in the postoperative period -- when the patient is awake and alert, thus improving the final surgical outcome.
3. Correction of Eyelid Retraction
Upper lid retraction can cause dry-eye symptoms and corneal exposure, and may even induce a corneal ulcer due to inadequate lid closure. It also contributes significantly to cosmetic disfigurement. Due to the tendency for spontaneous improvement, surgery for isolated upper lid retraction is usually performed only after at least one year of observation.
Eyelid retraction surgery is performed after decompressive and strabismus surgeries have been completed and the lid position has been stable for six months or more.
Upper lid retraction is corrected with a levator recession operation. The levator muscle (muscle that lifts the eyelid) is lengthened, thus allowing the upper lid to cover more of the eye. One can think of this operation as the opposite of a ptosis (drooping eyelid) repair.
Lower eyelid retraction is a common problem in TAO' patients. Patients with lower eyelid retraction complain of tearing, dryness, and foreign-body sensation. They frequently have evidence of exposure keratopathy. The most commonly used method of elevating the lid involves placing a tissue spacer within the back surface of the eyelid, thus effectively elongating the lower lid.
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