Eyelid musclesEyelid muscles
THE EYELID MUSCLESTHE EYELID MUSCLES
How the lids are kept in placeHow the lids are kept in place
Eyelid musclesEyelid muscles
The palpebral fissureThe palpebral fissure
Why do the eyelids not fall outwards?Why do the eyelids not fall outwards?
Why do the eyelids not turn inwards? Why do the eyelids not turn inwards?
How is the fissure width maintained?How is the fissure width maintained?
Eyelid musclesEyelid muscles
The palpebral fissureThe palpebral fissure
Why are they apposed to the globe –just so?Why are they apposed to the globe –just so?
TARSUS - CANTHAL LIGAMENTS – BONETARSUS - CANTHAL LIGAMENTS – BONE
Eyelid musclesEyelid muscles
The palpebral fissureThe palpebral fissure
Superior and inferior tarsusSuperior and inferior tarsusMedial and lateral canthal ligamentsMedial and lateral canthal ligaments
Lacrimal crests and lateral orbital tubercleLacrimal crests and lateral orbital tubercle
Eyelid musclesEyelid muscles
Horizontal lid laxityHorizontal lid laxity
Laxity of canthal ligamentsLaxity of canthal ligaments With gravity – With gravity – ectropionectropion With lid retractor laxity - With lid retractor laxity - entropionentropion
Eyelid musclesEyelid muscles
The palpebral fissureThe palpebral fissure
What keeps the upper lid up and the What keeps the upper lid up and the
lower lid down?lower lid down?THE EYELID RETRACTORS
Eyelid musclesEyelid muscles
Eyelid retractorsEyelid retractors
Upper lid retractorsUpper lid retractorsLevator aponeurosisLevator aponeurosisSuperior tarsal muscle (Muller’s)Superior tarsal muscle (Muller’s)
Lower lid retractorsLower lid retractorsCapsulopalpebral fasciaCapsulopalpebral fasciaInferior tarsal muscleInferior tarsal muscle
Orbital septum fuses with the retractorsOrbital septum fuses with the retractors
Eyelid musclesEyelid muscles
Eyelid retractorsEyelid retractors
Levator aponeurosisLevator aponeurosis Wide insertion Wide insertion Various layers of eyelidVarious layers of eyelid
Eyelid musclesEyelid muscles
Eyelid retractorsEyelid retractors
Levator aponeurosisLevator aponeurosisInsertionsInsertions1.1. Medial horn – posterior Medial horn – posterior
lacrimal crestlacrimal crest2.2. Lateral horn – lateral Lateral horn – lateral
orbital tubercleorbital tubercle3.3. Anterior portion – skinAnterior portion – skin4.4. Posterior portion – Posterior portion –
anterior tarsusanterior tarsus5.5. ConjunctivaConjunctiva
Eyelid musclesEyelid muscles
Eyelid retractorsEyelid retractors
Muller’s muscleMuller’s muscle
(superior tarsal muscle)(superior tarsal muscle) Posterior part of levatorPosterior part of levator 2 mm lift to the upper lid2 mm lift to the upper lid Insertion to tarsus and Insertion to tarsus and
conjunctivaconjunctiva Sympathetic supplySympathetic supply Horner’s syndrome – mild Horner’s syndrome – mild
ptosisptosis
Eyelid musclesEyelid muscles
Eyelid retractorsEyelid retractors
Lower lid retractor Lower lid retractor Capsulopalpebral fasciaCapsulopalpebral fascia From inferior rectus From inferior rectus
terminal fibresterminal fibres Encircles inferior Encircles inferior
oblique oblique Inserts to inferior Inserts to inferior
conjunctival fornix and conjunctival fornix and inferior tarsal border inferior tarsal border
Eyelid musclesEyelid muscles
Eyelid retractorsEyelid retractors
Upper lid retractorsUpper lid retractorsrarefactionrarefactiondisinsertion disinsertion PTOSISPTOSISdehiscencedehiscence
Lower lid retractorsLower lid retractors ECTROPIONECTROPIONattenuationattenuation ENTROPIONENTROPION
Eyelid musclesEyelid muscles
Result from imbalance between forces on Result from imbalance between forces on anterior and posterior lamellaeanterior and posterior lamellae
Ectropion - EntropionEctropion - Entropion
Eyelid musclesEyelid muscles
Ectropion - EntropionEctropion - Entropion
Initiator of imbalance – horizontal lid laxity
Tarsal instability
Gravity
Ectropion Entropion
lower lid retractor weakness
Eyelid musclesEyelid muscles
Outward turning of eyelid marginOutward turning of eyelid margin
TypesTypes
1.1. CongenitalCongenital
2.2. InvolutionalInvolutional
3.3. ParalyticParalytic
4.4. CicatricialCicatricial
5.5. MechanicalMechanical
EctropionEctropion
Eyelid musclesEyelid muscles
Most common type in practiceMost common type in practiceInvolutionalInvolutional
Primary etiologic factorPrimary etiologic factorHorizontal eyelid laxityHorizontal eyelid laxity
Clinical testClinical testThe snap testThe snap test
EctropionEctropion
Eyelid musclesEyelid muscles
Testing lid laxityTesting lid laxity
EctropionEctropion
Eyelid musclesEyelid muscles
Involutional ectropionInvolutional ectropionLower lidLower lidEpiphoraEpiphoraConjunctival Conjunctival
hypertrophyhypertrophyKeratinisationKeratinisation
EctropionEctropion
Eyelid musclesEyelid muscles
Paralytic ectropionParalytic ectropion
EctropionEctropion
Facial palsy
Eyelid musclesEyelid muscles
Cicatricial ectropionCicatricial ectropion
EctropionEctropion
Eyelid musclesEyelid muscles
Mechanical ectropionMechanical ectropion
EctropionEctropion
Eyelid musclesEyelid muscles
Inversion of eyelid marginInversion of eyelid margin
TypesTypes
1.1. CongenitalCongenital
2.2. Acute spasticAcute spastic
3.3. InvolutionalInvolutional
4.4. CicatricialCicatricial
Lower lid involutional entropion is Lower lid involutional entropion is
more common more common
EntropionEntropion
Eyelid musclesEyelid muscles
Involutional entropionInvolutional entropion
EntropionEntropion
Eyelid musclesEyelid muscles
Involutional entropionInvolutional entropion
EntropionEntropion
Eyelid musclesEyelid muscles
Results inResults in EpiphoraEpiphora Corneal abrasionsCorneal abrasions Corneal vascularizationCorneal vascularization
EntropionEntropion
Eyelid musclesEyelid muscles
MedialMedial
conjunctivoplasty/conjunctivoplasty/
Medial spindle Medial spindle
procedureprocedure
Ectropion surgeryEctropion surgery
Lateral canthoplasty/Lateral tarsal
strip procedure
Eyelid musclesEyelid muscles
Lazy-T procedureLazy-T procedure
MedialMedial
ConjunctivoplastyConjunctivoplasty
++
Full thickness Full thickness
excisionexcision
Ectropion surgeryEctropion surgery
Eyelid musclesEyelid muscles
Modified Modified
Kuhnt-Szymanowski Kuhnt-Szymanowski
procedureprocedure
Ectropion SurgeryEctropion Surgery
Eyelid musclesEyelid muscles
Transverse Transverse
lid everting suturelid everting suture
Entropion surgeryEntropion surgery
Eyelid musclesEyelid muscles
Weis procedureWeis procedure
Lid splitting Lid splitting
+ +
marginal rotationmarginal rotation
Entropion surgeryEntropion surgery
Eyelid musclesEyelid muscles
What is ptosis?What is ptosis?
It is an abnormally low It is an abnormally low position of the upper lid position of the upper lid
Eyelid musclesEyelid muscles
PtosisPtosis
How to How to diagnosediagnose mild ptosis? mild ptosis?What has What has causedcaused it? it?What is the What is the degreedegree of ptosis? of ptosis? Is it an indicator of a Is it an indicator of a seriousserious
disease?disease?How to choose the right How to choose the right
surgery surgery ??
Eyelid musclesEyelid muscles
PtosisPtosis
DiagnosisDiagnosisDrooping > 2 mm of cornea Drooping > 2 mm of cornea
coveredcoveredFrontalis overaction – forehead Frontalis overaction – forehead
wrinkleswrinklesChin elevation in bilateral ptosisChin elevation in bilateral ptosisRule out pseudoptosisRule out pseudoptosis
Eyelid musclesEyelid muscles
PtosisPtosis
Chin elevationChin elevation
Eyelid musclesEyelid muscles
PtosisPtosis
Brow elevationBrow elevation
Eyelid musclesEyelid muscles
PtosisPtosis
What has caused it?What has caused it?
ClassificationClassification• Congenital / AcquiredCongenital / Acquired• Lesion at the level ofLesion at the level of
nervenerve
musclemuscle
aponeurosisaponeurosis
Eyelid musclesEyelid muscles
PtosisPtosis
EtiologyEtiology
1.1. MyogenicMyogenic
2.2. AponeuroticAponeurotic
3.3. NeurogenicNeurogenic
4.4. MechanicalMechanical
5.5. TraumaticTraumatic
Eyelid musclesEyelid muscles
PtosisPtosis
MMost common acquired ptosisost common acquired ptosis
AponeuroticAponeurotic
MMost common congenital ptosisost common congenital ptosis
MyogenicMyogenic
Eyelid musclesEyelid muscles
PtosisPtosis
Congenital myogenic ptosisCongenital myogenic ptosis
Eyelid musclesEyelid muscles
PtosisPtosis
Aponeurotic ptosisAponeurotic ptosis
Eyelid musclesEyelid muscles
PtosisPtosis
Paralytic ptosisParalytic ptosis
Eyelid musclesEyelid muscles
PtosisPtosis
Mechanical ptosisMechanical ptosis
NeurofibromatosisNeurofibromatosis
Eyelid musclesEyelid muscles
PtosisPtosis
AAponeurotic ptosisponeurotic ptosis
InvolutionalInvolutional
PostoperativePostoperative
MechanismMechanism
rarefactionrarefaction
disinsertiondisinsertion
dehiscencedehiscence
Eyelid musclesEyelid muscles
PtosisPtosis
AAponeurotic ptosisponeurotic ptosis aging / surgeryaging / surgery high upper lid creasehigh upper lid crease
normal – 8-10 mmnormal – 8-10 mm
levator attachments to skinlevator attachments to skin
thinning of lidthinning of lid near normalnear normal levator functionlevator function
Eyelid musclesEyelid muscles
PtosisPtosis
AAponeurotic ptosisponeurotic ptosis
Brow elevation, high crease,
deep sulcus, thinned lid
Eyelid musclesEyelid muscles
PtosisPtosisCCongenital ptosisongenital ptosisSimpleSimple developmental dystrophy of developmental dystrophy of
levator musclelevator muscle Absent / weak lid creaseAbsent / weak lid crease reduced levator functionreduced levator function
Eyelid musclesEyelid muscles
PtosisPtosis
CCongenital ptosisongenital ptosis
SimpleSimple lid lag in downgazelid lag in downgaze weakness of superior rectus weakness of superior rectus
+/-+/- amblyopia from amblyopia from
astigmatismastigmatism
anisometropiaanisometropia
occlusionocclusion
Eyelid musclesEyelid muscles
PtosisPtosis
CCongenital ptosisongenital ptosis
Obscuring visual axis
Eyelid musclesEyelid muscles
PtosisPtosis
Marcus Gunn jaw-winking syndromeMarcus Gunn jaw-winking syndrome
CCongenital ptosisongenital ptosis
Eyelid musclesEyelid muscles
PtosisPtosis
Congenital Congenital
MyogenicMyogenic
Mild to severeMild to severe
ptosisptosis
Acquired Acquired
AponeuroticAponeurotic
Mild to severeMild to severe
ptosisptosis
PalpebralPalpebral
fissure heightfissure height
Eyelid musclesEyelid muscles
PtosisPtosis
Congenital Congenital
MyogenicMyogenic
Weak orWeak or
absentabsent
Acquired Acquired
AponeuroticAponeurotic
Higher thanHigher than
normalnormal
Upper eyelidUpper eyelid
CreaseCrease
Eyelid musclesEyelid muscles
PtosisPtosis
Congenital Congenital
MyogenicMyogenic
ReducedReduced
Acquired Acquired
AponeuroticAponeurotic
Near normalNear normalLevatorLevator
functionfunction
Eyelid musclesEyelid muscles
PtosisPtosis
Congenital Congenital
MyogenicMyogenic
Eyelid lagEyelid lag
Acquired Acquired
AponeuroticAponeurotic
Eyelid dropEyelid dropOn downgazeOn downgaze
Eyelid musclesEyelid muscles
PtosisPtosis
AsAs an indicator of a serious disorder an indicator of a serious disorder
Myasthenia gravisMyasthenia gravis ocular involvement in 90%ocular involvement in 90% presenting feature in 60%presenting feature in 60% variable ptosis, bilateral, variable ptosis, bilateral,
asymmetricasymmetric worsens towards eveningworsens towards evening Tensilon testing Tensilon testing
Eyelid musclesEyelid muscles
PtosisPtosis
AsAs an indicator of a serious disorder an indicator of a serious disorder Myasthenia gravisMyasthenia gravis
Ptosis RE Ptosis LE, 3 months later
Eyelid musclesEyelid muscles
PtosisPtosis
AsAs an indicator of a serious disorder an indicator of a serious disorder
Neurogenic ptosisNeurogenic ptosis oculomotor nerve palsyoculomotor nerve palsy
diabetes / diabetes / hypertensionhypertension
intracranial intracranial aneurysmsaneurysms
/ tumors / trauma/ tumors / trauma check for III nerve functionscheck for III nerve functions
Eyelid musclesEyelid muscles
PtosisPtosis
Pancoast’sPancoast’s tumor / carotid aneurysms / malignant tumor / carotid aneurysms / malignant cervical lymph nodes cervical lymph nodes
Horner’s syndrome
before cocaine after cocaine
Eyelid musclesEyelid muscles
PtosisPtosis
AsAs an indicator of a serious disorder an indicator of a serious disorder
NNeurogenic ptosiseurogenic ptosis• Oculosympathetic palsyOculosympathetic palsy
(Horner’s syndrome)(Horner’s syndrome) mild ptosis as a rulemild ptosis as a rule miosismiosis normal pupillary reactionsnormal pupillary reactions Pancoast’s tumor / carotid Pancoast’s tumor / carotid
aneurysms / malignant cervical aneurysms / malignant cervical lymph nodeslymph nodes
Eyelid musclesEyelid muscles
PtosisPtosis
DDegree of ptosisegree of ptosis
MeasurementsMeasurements• Palpebral fissure heightPalpebral fissure height• Margin reflex distanceMargin reflex distance• Upper eyelid creaseUpper eyelid crease• Levator functionLevator function
Eyelid musclesEyelid muscles
PtosisPtosis
DDegree of ptosisegree of ptosis
MeasurementsMeasurements
Poor levator function
Eyelid musclesEyelid muscles
PtosisPtosis
DDegree of ptosisegree of ptosis
MeasurementsMeasurements
Ptosis data sheet
Eyelid musclesEyelid muscles
PtosisPtosis
DDegree of ptosisegree of ptosis
MeasurementsMeasurements
Amount PtosisAmount Ptosis ClassificationClassification
less than or equal to 2mmless than or equal to 2mm MildMild
3mm3mm ModerateModerate
greater than or equal to 4mmgreater than or equal to 4mm SevereSevere
Amount of droop from normal
Eyelid musclesEyelid muscles
PtosisPtosis
DDegree of ptosisegree of ptosis
MeasurementsMeasurements
Levator function
Levator Muscle ExcursionLevator Muscle Excursion ClassificationClassification
15mm15mm NormalNormal
greater than or equal to 8mmgreater than or equal to 8mm GoodGood
5-7mm5-7mm FairFair
less than or equal to 4mmless than or equal to 4mm PoorPoor
Eyelid musclesEyelid muscles
PtosisPtosis
AAdditional testsdditional testsOcular motilityOcular motilityLid in downgazeLid in downgazeAmblyopia Amblyopia Bell’s phenomenonBell’s phenomenonPharmacologic testingPharmacologic testing
Eyelid musclesEyelid muscles
PtosisPtosis
SSurgeryurgery
Dependent on levator functionDependent on levator function
Normal function
Levator aponeurosis advancement / reinsertion
Eyelid musclesEyelid muscles
PtosisPtosis
SSurgeryurgeryDependent on levator functionDependent on levator functionFor mild ptosisFor mild ptosis
Mild ptosisHorner’s
Fasanella-Servat procedure(tarsoconjunctival)Muller’s muscle resection
Eyelid musclesEyelid muscles
PtosisPtosisSSurgeryurgery
Dependent on levator functionDependent on levator function
Moderate tosevere ptosis
Levator resection Amount of resection according to degree of ptosis
Eyelid musclesEyelid muscles
PtosisPtosis
SSurgeryurgery
Dependent on levator functionDependent on levator function
Absent function
Frontalis suspensionAutogenous fascia lata or synthetic materials
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