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बुधवार, 16 फ़रवरी 2011

Lagophthalmos: and ptosis

Definition : Incomplete closure of the palpabral aperture when attempt is made to close the eyes

Causes of Lagophthalmos

Contraction of lids due to cicatrization or a congenital deformity
Ectropion
Paralysis of Orbicularis
Proptosis due to exophthalmic goitre, orbital tumour/ inflammmation etc.
Laxity of tissue and absence of reflex blinking who are extremely ill.

Clinical Picture

Symptoms:
1.Inability to close eye(s)
2.Symptoms of dry eye
3.Blurring of vision
4.Foreign body sensation
5.Photophobia 

Signs
1.Incomplete closure of lid
2.Exposure of conjunctiva and cornea
3.Dryness, congestion
4.Hazyness of cornea, punctate infiltration
Complications
1. Corneal ulcer (Non-healing)
'� - a (�] x`] bri;font-size:178%'>1.Inability to close eye(s)
2.Symptoms of dry eye
3.Blurring of vision
4.Foreign body sensation
5.Photophobia 

Medical Treatment
1.Lubricating Eye drops
2.Control of infection
3.Protection of ocular surface
Surgical Treatment:
Tarsorrhaphy  (Lateral or paramedian)
. Corneal ulcer (Non-healing)

Ptosis

Definition: Drooping of upper lid usually due to paralysis or defective development of the levator palpebrae superioris (LPS) 

Types

Congenital
1. Simple
2. Complicated
Acquired
1. Neurogenic
2. Myogenic
3. Aponeurotic
4 Mechanical

Pseudoptosis – in Phthisis bulbi and anophthalmos
Condition may be Unilateral or Bilateral
Partial or complete
Measurement 

Normal position of lids
Abnormal – Margin Reflex Distance (MRD)- Normal MRD is 4 mm +/- 1 mm
Ptosis of less than 2 mm – Mild
Ptosis of 3 mm – moderate
Ptosis of 4 mm or more – severe

Compensatory Mechanism 

Overaction of frontalis
Throwing back the head
Assessment of LPS function –
Excursion of 8 mm or more – good action
Excursion of 5-7 mm – Fair action
Excursion of 4 mm or less – poor
Look for Bell phenomenon 

Congenital Ptosis

Commonest form of ptosis
Usually bilateral / Heriditary
Due to defective development of LPS
Simple congenital ptosis is an isolated abnormality

Complicated – when associated with developmental abnormality of surrounding structures
Associated Sup rectus palsy
Abnormal synkineses – Marcus Gunn ptosis
Dystrophy of the LPS  
Blepharophimosis syndrome (Ptosis, horizontal shortening of palp aperture, epicanthus inversus, telecanthus lat ectropion of the lower lids)

Treatment of Congenital Ptosis 

Age (3-5 years), early surgery when pupil is covered
Fasanella –servat operation (indicated when ptosis is 1.5 – 2 mm – excision of 4-5 mm upper tarsus)
LPS resection – 10 mm resection is minimum (resection ranges from 12 – 24 mm)
Conjunctival (Blaskovics operation) or skin (Everbusch operation) route for surgery

Frontalis suspension- intact LPS with poor function (3 mm or less)
4-0 Supramid suture or fascia lata is used
Complications associated with this operation
Acquired Ptosis

Usually unilateral
Types
1.Neurogenic – Third nerve paralysis or due to reduced sympathetic innervation (Horner syndrome – ptosis, anhydrosis and miosis)
Treatment – of cause, crutch spectacle, surgery – LPS resection/ Frontalis suspension

2. Myogenic – gradual onset, bilateral condition, symmetrical
Myotonic dystrophy
Chronic progressive exophthalmoplegia
Mysthenia gravis ( damage to acetyl-cholin receptor at postsynaptic membrane with presence of antiacetylcholine receptor antibodies)

Aponeurotic Ptosis
Is involutional is due to weakness or disinsertion of LPS aponeurosis from ant surface of tarsal plate
High lid fold with good LPS function
Treatment – reinsertion of LPS and resection of LPS
Mechanical  Ptosis - Tumour or inflammation weigh down the lid




Contusions
Black Eye – swelling and ecchymosis of lids and conjunctiva
Cryptophthalmos – rare condition characterized by presence of skin passing continuously from brow over the eye to the cheek.








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