SARI PUSTAKA II

A.A.Ayu Githasari Dewi

 INTRODUCTION
• Blepharoptosis=ptosis
• One of the common eyelid disorders 1
• Aponeurotic ptosis  the most common of acquired ptosis 2
• Incidence  11,5% in people over 50 y.o in UK 3
• Symptom : ranging from significant visual disturbances or
cosmetically
• May be a reduction of the visual field, which impedes the
performance of activities of daily living. Thus, early
diagnosis and appropriate management of ptosis is
essential.
1. Riordan EP, Whitcher JP. 2011. Lids & Lacrimal Apparatus. In: Vaughan and Asbury’s General Ophthalmology. 18th ed. Boston:
McGraw-Hill, P.67-82
2. Grover AK, Bajega S, Taneja S. Long Case of Ptosis. E Journal of Ophthalmology. 2013. Available at :
http://www.ejournalofophthalmology.com/ejo/ejo13.html
3. Javier GM. Aponeurotic Ptosis. 2017. Available at : http://eyewiki.aao.org/Aponeurotic_ptosis#Disease
 DEFINITION

• Ptosis  Upper eyelid drop below the normal

position when the eye is open4

• Aponeurotic ptosis  stretching or disinsertion of

the levator aponeurosis.4

4. American Academy of Ophthalmology Staff . The Patient With Eyelid or Facial Abnormalities. In: Basic And Clinical Science Course-
Neuro Opthalmology. Section 5. San Fransisko: American Academy of Ophthalmology. 2016-2017. P- 297-300.
 EPIDEMIOLOGY

• Ethnic and sexual predilections are unknown.5

• Ptosis is increasingly common in elderly patients. 6

• A study in the UK that looked at individuals aged 50

years and over found that 11.5% of the population
had ptosis and the prevalence of ptosis increased
with age.6

5. Baiyeroju AM, Oluwatosin OM. Blepharoptosis in Ibadan, Nigeria; West Afr J Med. 2003 Sep;22 (3):208-10.
6. Sridharan GV, Tallis RC, Leatherbarrow B, Forman WM. A community survey of ptosis of the eyelid and pupil size of elderly people.
Age Ageing.1995;24(1):21-4.
ANATOMY EYELID
 EYELID ANATOMY

7. American Academy of Ophthalmology Staff . Facial and eyelid anatomy. In: . Basic and clinical course-Orbit, eyelids, and lacrimal
system. Section 7. San Fransisko: American Academy of Ophthalmology. 2016-2017. P. 166-77, 243-54.
 EYELID ANATOMY

7. American Academy of Ophthalmology Staff . Facial and eyelid anatomy. In: . Basic and clinical course-Orbit, eyelids, and lacrimal
system. Section 7. San Fransisko: American Academy of Ophthalmology. 2016-2017. P. 166-77, 243-54.
 ETIOLOGY

• Most causes secondary to involutional changes in

the levator aponeurosis. 8

• Risk factor : continuous rubbing of the eye, chronic

use of contact lenses, inflammatory diseases,
intraocular surgery. 2,3

• Approximately 6% of patients following cataract

surgery develops ptosis. 2,3

1. Grover AK, Bajega S, Taneja S. Long Case of Ptosis. E Journal of Ophthalmology. 2013. Available at :
http://www.ejournalofophthalmology.com/ejo/ejo13.html
2. Javier GM. Aponeurotic Ptosis. 2017. Available at : http://eyewiki.aao.org/Aponeurotic_ptosis#Disease
8. Sudhakar P. Upper Eyelid Ptosis Revisited. American Journal of Clinical Medicine. 2009.
 SYMPTOMS

• Symptom: asymptomatic cosmetic eyelid 

visually significant obstruction. 9

• Visual field obstruction. 9

• Frontalis fatigue or even cephalgia (overaction of

the frontalis muscle). 9

9. Shome D. Aponeurotic Ptosis (Adult Onset Aqcuired Ptosis). 2016. Available at : http://oculoplastic-eyelid-orbit-
surgery.com/service/adult-senile-aponeurotic-ptosis/
 SIGN
• Aponeurotic ptosis: good levator function,
elevation or absence of Upper Eyelid crease
Position and thinning of the eyelids on the tarsal
plate. 10,11

10. Deady JP, Morrell AJ, Sutton GA. Recognising Aponeurotic Ptosis. Journal of Neurology, Neurosurgery and Psychiatry. 1989;52:996-8.
11. Newman, Steven A. 2001. Eyelid Malposition and Involutional Changes, The Foundation of The Academy Of Oftalmology. San
Fransisco.P.190-200.
 DIAGNOSIS

• Anamnesis
• Physical examination
• Ptosis evaluation
• Palpebral Fissura Height
• Margin Reflex Distance
• Upper Eyelid Crease
• Levator Function
• Presence of Lagopthalmos
• Margin Limbal Distance
• Bell’s phenomenom
10. Deady JP, Morrell AJ, Sutton GA. Recognising Aponeurotic Ptosis. Journal of Neurology, Neurosurgery and Psychiatry. 1989;52:996-8.
11. Newman, Steven A. 2001. Eyelid Malposition and Involutional Changes, The Foundation of The Academy Of Oftalmology. San
Fransisco.P.190-200.
 DIFFERENTIAL DIAGNOSIS
• Blepharophimosis Syndrome 8,12

• Marcus Gunn’s Jaw Winking Syndrome 13

8. Sudhakar P. Upper Eyelid Ptosis Revisited. American Journal of Clinical Medicine. 2009
12. Allen C, Rubin P. Blepharophimosis-ptosis-epicanthus Inversus Syndrome (BPES): Clnical Manifestation and Treatment. International
Ophthalmology Clinics 2008; 48(2): 15-23.
13. Demirci H. Marcus Gunn Jaw-Winking Synkinesis. Ophthalmology 2010;117(7):1447-52.
 DIFFERENTIAL DIAGNOSIS

• Horner Syndrome 14

• Myasthenia Gravis 14

14. Wesley BS, Jesse MV, Richard CA. A Primer on Ptosis. Ophthalmology an Visual Sciences-University of IOWA Healrh Care. 2015.
Available at : http://webeye.ophth.uiowa.edu/eyeforum/tutorials/ptosis/index.htm
 DIFFERENTIAL DIAGNOSIS
• Chronic progressive external ophthalmoplegia 1

• Mechanical Ptosis 14

1. Riordan EP, Whitcher JP. 2011. Lids & Lacrimal Apparatus. In: Vaughan and Asbury’s General Ophthalmology. 18th ed. Boston:
McGraw-Hill, P.67-82
14. Wesley BS, Jesse MV, Richard CA. A Primer on Ptosis. Ophthalmology an Visual Sciences-University of IOWA Healrh Care. 2015.
Available at : http://webeye.ophth.uiowa.edu/eyeforum/tutorials/ptosis/index.htm
 TREATMENT 2,15

• Levator resection

• Muller’s muscle resection

• Frontalis sling

2. Grover AK, Bajega S, Taneja S. Long Case of Ptosis. E Journal of Ophthalmology. 2013. Available at :
http://www.ejournalofophthalmology.com/ejo/ejo13.html
15. Wei YH, Liao SL. Frontalis Suspension Using Expanded Polytetrafluoroethylene: Result of Differet Surgical Design. 2009. J Formos
Med Assoc. 108:943.
 COMPLICATION

• Complication : undercorrection, overcorrection,

lagofthalmos 1

• Other potential complications are hemorrhage,

infection, poor wound healing, traumatize the
superior oblique muscle or lacrimal gland ductules.
unsatisfactory or asymmetric eyelid contour,
scarring, eyelid crease asymmetry, conjunctival
prolapse, tarsal eversion, and lagophthalmos with
exposure keratitis. 1
1. Riordan EP, Whitcher JP. 2011. Lids & Lacrimal Apparatus. In: Vaughan and Asbury’s General Ophthalmology. 18th ed. Boston:
McGraw-Hill, P.67-82
 PROGNOSIS

• Depend on severity and onset of ptosis

• Most of surgery procedure give a good result and

bring the eyelid into normal position 16

16. Brenda C, Edmonson, Allan EW. Ptosis Evaluation and Management. Otolaryngologic Clinics of North America. 2005;38:921-46.
 SUMMARY

• Aponeurotic ptosis: stretching or disinsertion of the

levator aponeurosis
• Symptom : ranging asymptomatic cosmetically
until significant visual disturbances
• Examination is important to diagnose ptosis
(severity and cause of ptosis)  appropriate
management
• Definitive treatment : surgery procedure
Thank you