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Ptosis Surgery
Arnab Biswas
1:
Eyelid Anatomy
Introduction
Surface Anatomy
Overview of Structure
Skin and Subcutaneous Tissue
Orbicularis Oculi Muscle
Parts
Function
Innervation
Origin and Insertion
Submuscular Areolar Tissue
Tarsal Plates
Medial Palpebral Ligament
Lateral Palpebral Ligament
Orbital Septum
Levator Palpebra Superioris
Origin
Course
Insertion
Innervation
Function
Müller's Muscle
Origin
Insertion
Action
Lower Lid Retractors
Fat Pads
Conjunctiva
Nerves
Sensory innervation
Motor Innervation
Vessels
Lymphatic Drainage
2:
Applied Surgical Anatomy
Introduction
Surgical Disection of the lid through Anterior Approach
Skin and Subcutaneous tissue
Orbicaluris Oculi and Orbital Septum
Levator aponeurosis
Preaponeurotic fat pad
Whitnall's ligament
Horns of Levator Muscle
Müller's muscle
All the structures from skin to Müller's muscle
Surgical Dissection of the lid through Posterior Approach
Everted Upper Lid
Tarsal Conjunctiva
Layers of the Lid
Levator Aponeurosis
3:
Classification of Ptosis
Introduction
Important Observations
Congenital/Childhood Ptosis
Causes
Acquired/Adult onset Ptosis
Causes
Detailed classification of Ptosis
1. Congenital ptosis
2. Acquired ptosis
Syndromes and diseases associated with Ptosis
Specific Blepharoptosis
Pseudoptosis
4:
Clinical Evalution
History
Algorithm for History Taking in a Patient of Ptosis
Physical Examination
Bell's Phenomenon Evaluation
Algorithm of Clinical Evaluation for a Patient of Ptosis
Schematic comparing ptosis (in mm) to MRD
Ptosis measurements
Simple observation
Upper lid height
Levator function
Additional observations:
Algorithm for a Patient with Ptosis and associated Strabismus
Laboratory Studies
Imaging Studies
Other Tests
Procedures
Eyelid Measurements
5:
Types of Ptosis
Congenital Simple Ptosis
Genetics
Pathophysiology
Clinical Features
Management of Ptosis
Standard Therapies
Blepharophimosis Syndrome
Standard Therapies
Diagnosis
Treatment
Management of Ptosis
Marcus Gunn Jaw-winking Ptosis
Background
Genetics
Pathophysiology
Associations
Race
Sex
Clinical Presentation
Gradation of Jaw-wink
Treatment
Medical Care
Surgical Care
Strabismus surgery
Management of Ptosis
Ptosis Surgery
IIIrd Cranial Nerve Palsy
Signs and Symptoms
Pathophysiology
Management of Medial third cranial nerve palsy
Medical Care
Algorithm for a suspected case of 3rd Cranial Nerve Palsy
Surgical Third Cranial Nerve Palsy
Surgical Care
Management of Ptosis
Role of Pupil Evaluation in a Case of Ptosis
Chronic Progressive External Ophthalmoplegia
Pathophysiology
Genetics
Sex
Age
Clinical Features
History
Differential Diagnosis
Laboratory Studies
Imaging Studies
Other Tests
Histologic Findings
Medical Care
Management of Ptosis
Differential Diagnosis of Ocular Myopathies
Horner's Syndrome
Causes
Pharmacological tests for Localization of Lesion
Test to document ocular sympathetic lesion
Test to localize lesion (preganglionic or postganglionic)
Signs and Symptoms
Other Ocular findings
Association
Management
Management of Ptosis
Myasthenia Gravis
Pathophysiology
Frequency
Race
Sex
Age
Clinical
History
Physical
Causes
Laboratory Studies
Imaging Studies
Other Tests
Treatment options of Myasthenia gravis
MEDICATION
Cholinesterase inhibitors
Management of Ptosis
Aponeurotic ptosis
Pathophysiology
Causes
Clinical Features
Management of Ptosis
Dermatochalasis
Introduction
Pathophysiology
Systemic Association
Clinical Manifestation
Management Options
Blepharochalasis
Pathophysiology
Clinical Manifestation
Management Options
Medical Therapy
Surgical Therapy
Pseudoptosis
Mechanical Displacement of Lid
Unilateral lid retraction
Microphthalmos or anophthalmos
Duane syndrome
Vertical muscle imbalance
Ptosis with Ocular Motility Disorders
6:
Decision Making
Medical Management
Surgical Management
History of the Procedure
Preoperative Details
Ptosis Surgery
Congenital
Algorithm for Surgical Management for a Ptosis Patient
Surgical Options
How much to Resect?
Marcus Gunn (Jaw-winking) Ptosis
Surgical Options
Important Observation
Acquired Ptosis
Aponeurotic, Traumatic and Iatrogenic ptosis
Surgical Options
Neurogenic/Myogenic ptosis
Surgical Options
Mechanical ptosis
Chronic Progressive External Ophthalmoplegia (CPEO)
Surgical Options
Blepharophimosis Syndrome
Surgical Options
Timing of Surgery
Congenital Ptosis
Acquired or secondary ptosis
Contraindications
Postoperative Details
Follow-up
7:
Standard Surgical Procedures
Goals of Ptosis Surgery
Anesthesia
General anesthesia
Local anesthesia
Fasanella-Servat Procedure
Introduction
Indication
Contraindication
Algorithm for Fasanella Procedure
Anesthesia
Surgical Steps
Surgical steps of Fasanella-Servat Procedure
Anterior Approach for Levator Resection
Introduction
Indications
Contraindications
How much to Resect ?
Amount of levator resection based on Beard's pre-operative evaluation
Anesthesia
Surgical Steps
Surgical Steps of Anterior Approach for Levator Resection
Levator aponeurosis repair in Aponeurotic Ptosis
Introduction
Indication
Contraindication
Anesthesia
Surgical Steps
Surgical Steps of Levator Aponeurosis Repair
Frontalis Sling Procedure
Introduction
Harvesting Fascia Lata
Anesthesia
Age of Surgery
Positioning of leg
Pertinent Anatomy
Preoperative Preparation
Evaluation
Site of Incision
Surgical Steps
Postoperative Management
Potential Complications
Handling of Extracted Fascia Lata
Fascia Lata Frontalis Sling Procedure
Indication
Contraindication
Surgical Steps
Surgical steps of Frontalis sling (Fox's Technique)
Postoperative Details
Follow-up
8:
Miscellaneous Surgeries
Frontalis Sling with Silicone (Synthetic Material)
Indications
Surgical Steps of Frontalis Sling with Silicone
Surgical correction of Marcus Gunn Jaw-winking Ptosis
Treatment options
Surgical Technique
Posterior Approach for Levator Resection
Epicanthus
Telecanthus
Surgical Options
Complications of Surgery
Ectropion
Cantholysis
Indication
Removal of Excess Skin
Causes
9:
Complication and Management
Overcorrection
Causes
Management
Mullerectomy for overcorrection (Internal Approach)
Spacers for overcorrection (Internal Approach)
Spacers for overcorrection (External Approach)
Surgical Steps
Undercorrection
Causes
Management
Entropion
Cause
Management
Surgical Correction of Entropion
Ectropion
Cause
Management
Surgical Correction of Ectropion
Infection and inflammatory Reactions
Causes
Management
Late granulomatous inflammatory reactions
Management
Corneal abrasion
Cause
Management
Excess skin
Causes
Surgical Removal of Excess Skin
Exposure keratitis
Causes
Management
Conjunctival prolapse
Cause
Management
Peaking of the lid
Causes
Management
Surgical Management of Poorly Formed Lid Crease
Lid lag & Lagophthalmos
Hemorrhage
Double vision
Summary
10:
Instrument and Anesthesia
Instruments for Ptosis Surgery
Ptosis Special instruments
Sutures
Ptosis Crutch
Mechanism of Action
Indication
Anesthesia for ptosis surgery
General anesthesia
Local anesthesia
Regional Sensory Blocks
Infiltration Anesthesia
Regional Block
Supraorbital nerve block
Lacrimal nerve block
Supratrochlear nerve Block
BIBLIOGRAPHY
INDEX
TOC
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