Lecture: Ptosis 101: Evaluation and Management

DR. RON PELTON: Hello and welcome. Good morning, good afternoon, or good evening, wherever you are in the world. I’m Ron Pelton, I’m an ocular plastic surgeon here in Colorado. I’m happy to be here with my good friend and esteemed colleague, Dr. Andrea Tooley in Kentucky. We want to welcome everyone, and thank you for joining us from so many different time zones and so many different corners of the world for this Orbis International session on ptosis. It really is an honor and a privilege to be with so many in our global community who are committed to saving sight and to improving eyelid function. So today we’re going to take a practical tour through ptosis. We’re going to start with eyelid anatomy, then we’re going to move through the different types of ptosis and how to evaluate ptosis. And then Dr. Tooley’s going to walk us through some practical tips on surgical and nonsurgical ways of treating ptosis. So we’re also going to spend some time at the end of this session trying to answer your questions and to help you with ways that you might be able to treat ptosis there in your community. And so with that, we’ll get started. So these are our learning objectives today. We want to, of course, understand eyelid ptosis because — the anatomy of eyelid ptosis, because once you understand anatomy, the ways we treat ptosis kind of become intuitive. We’re going to talk about classification of ptosis. We’re going to talk about the key elements of evaluation for ptosis. And then, again, we’re going to talk about how to choose the appropriate surgical or nonsurgical approach to ptosis. Before we begin, we want to ask some questions to see maybe where our audience is with regard to ptosis. So the most common type of eyelid ptosis is which one of these? So you can choose congenital or genetic, or levator dehiscence, that’s age-related, or paralytic ptosis, mechanical ptosis, or traumatic ptosis. Go ahead and make your choice now. Okay. Great. Let’s move on to our next question. So what type of ptosis is this? Is this congenital or genetic? Is it age-related, levator dehiscence ptosis? Is it paralytic? Or is it mechanical? Well, one of the options I can see isn’t here is neurogenic or paralytic. Okay. This is our last question. What’s the most common complication of ptosis surgery? Is it overcorrection, or undercorrection? Is it trauma to the cornea? Or is it some type of lid deformity? All right. Very good. Well, again, to truly understand how to evaluate ptosis, and how to choose the correct surgical approach, we need to understand the eyelid anatomy. And we’re going to sort of walk through this in the same way that you would if you were actually doing surgery on the eyelid. So obviously the first piece of anatomy that we will encounter is the skin. And right under the skin is the orbicularis muscle. And Andrea will sort of show you that during the surgical videos. The next thing that we’re looking for is the orbital septum. Remember, the orbital septum is the little piece of tissue that sort of separates the orbit from the anterior eyelid. And that’s going to be a very important anatomical landmark. And then the pre-aponeurotic fat. Once you find that fat, it’s a great landmark so you’ll know where you are. And ultimately what we’re looking for is this, the levator aponeurosis. Remember, that’s the tendon of the levator muscle. And then we can see where the tendon inserts on the muscle. Again, that’s a very, very important landmark. One of the things that you’ll sometimes see is Muller’s muscle. That’s the next layer. And then lastly, the tarsus, again, a very important piece of anatomy, because this is what you’re going to suture the tendon back to. So the etiology of ptosis. There are multiple reasons why someone might have a droopy eyelid. And one is congenital. And then of course we have age-related levator dehiscence, that’s when the tendon pulls away from the tarsus. The next is paralytic or neurogenic. Then we have mechanical, and traumatic ptosis. So this is congenital ptosis. It occurs evenly across different races. You can see that all of these children have a droopy eyelid. And then it occurs evenly amongst male and female. As a there doesn’t seem to be any racial or sex predisposition to having ptosis. It’s usually seen at birth, but sometimes it can be subtle enough that the parents don’t pick up on it until later on in life. And then we’ll move on to the most common type of ptosis. This is age-related levator dehiscence. This is when that tendon which attaches to the upper part of the tarsal plate pulls away. Now, the hallmark of levator dehiscence is this hollowness in the upper eyelids. When you see this, you know that the levator muscle, the tendon, has pulled off of the tarsal plate and has retracted, pulling the skin with it. When you see this, you know exactly what type of ptosis you’re dealing with. And personally I find this is the most easy type of ptosis to correct, because once you reattach the tendon, then the patient’s ptosis disappears. The next type of ptosis is paralytic or neurogenic. So this person has a third nerve palsy. Now, neurogenic or third nerve palsy ptosis is something that definitely needs to be investigated for congenital ptosis, for age-related ptosis. We don’t typically do any kind of imaging or other type of workup, but this is one where we definitely need to do a workup. The cause of a third nerve palsy can sometimes be something that is a true emergency. In fact, I was taught by my neuro-ophthalmology colleagues that when you see a painful third nerve pupil-involved palsy, that’s an aneurysm of the posterior communicating artery until proven otherwise. So if you see a paralytic or neurogenic type of ptosis, and if you think it’s a third nerve palsy, because you can see how when you lift the eyelid here, how the eye is retracted laterally, you need to get your neuro-ophthalmology colleagues or your neurology colleagues involved, and we may even also need to get interventional radiology or potentially even neurosurgical colleagues involved. So this is one you definitely don’t want to miss, ever. Mechanical ptosis, luckily, is something that is relatively uncommon. The times that I’ve seen it, it’s either been from — in a child like this, with a large capillary hemangioma. And it’s just the weight of that tumor in the eyelid that’s pulling it down. So typically, with these sorts of — this sort of ptosis, if you can remove the tumor or at least treat the tumor and shrink it, the eyelid tends to come back up. Obviously in a child this is something that is an urgency because of potential for amblyopia. So it’s something that you definitely want to treat. Now, in adults, the most common type of mechanical ptosis that I’ve seen has to do with other types of tumors, mostly skin cancers. Sometimes large, neglected skin cancers can pull the eyelid down as well. Lastly, we have traumatic ptosis. This one’s pretty obvious. You can see this patient’s eyelid has been torn away. And with it, the levator muscle has been torn off as well. Sometimes this can be very easy, very straightforward to fix. Sometimes it can be difficult. This one tends to be pretty obvious. Let’s talk a little bit about evaluation of ptosis. I think this is probably one of the most important parts of looking at ptosis, because depending on what our measurements are, what our evaluation is, that’s going to help us determine what we’re going to do to treat the ptosis. These are what re tend to look at, the MRD or margin to reflex distance. The reflex refers to the reflex of the light. So when you show a small flashlight into the patient’s eye, all see the little white dot in the middle of the pupil. And the distance from that to the edge of the eyelid is the MRD1. I should say, the upper eyelid, the MRD1. That gives you an idea of the depth of the ptosis. And it’s also important to note the MRD2. And that’s the distance from the light reflects to the edge of the bottom eyelid. In some people that you’ll see, the MRD2 is very small. So when you fix the upper eyelid, when you raise the upper eyelid to a normal height, sometimes people still look like they have a small eye. And if you don’t recognize or notice that their MRD2 is very small, you’ll be wondering why the eyelid didn’t looking bigger. So when you’re doing surgery, when I’m doing surgery, sometimes I will reattach the levator aponeurosis tendon, I’ll get the upper eyelid to a good height. My assistant says the eye still looks small. It’s because the lower eyelid can sometimes raise all the way up to the pupil as well. And one of the other things you want to measure is the edge of the eyelid or the margin distance up to their lid crease. So we’ll talk about that a little bit more in a minute. So this is an MRD of about 4. That’s about normal. You can see the MRD2 here is probably about six. And I tell patients that the lower lid should just kiss the colored part of the eye, just right on the very edge, whereas the upper eyelid should be down on the colored part, maybe 1 or 2 millimeters. So this is someone who has a normal eyelid with a normal MRD, whereas this patient has a very small MRD1. This MRD1 is about a millimeter or so. You can see that white light reflex there right on the very edge of the eyelid. Whereas this one is an MRD of zero. An MRD1 of zero. So the upper eyelid is so ptotic that it’s now covered up most of the pupil. You can also see the bit of hollowness up there. So you know that this patient is probably suffering from an age-related ptosis, a levator dehiscence ptosis. One of the things we often measure is this IPF, interpalpebral fissure. People can have a very small interpalpebral if they have a very short MRD2. This is something else you want to measure. The margin to fold distance, the MFD, or the distance from the edge of the eyelid to the crease or fold, is different for men and women. We tend to anything that men have a lid crease that’s about somewhere around 8 to 10 millimeters in height, and women tend to be more like 10 or 12. Now, there’s a wide variation on this, depending on the race, depending on the sex. So these are just sort of general numbers. And it will be different from person to person. You can have a woman with an 8-millimeter lid crease and she’s completely normal. In some of our Asian patients, we’ll actually see a lid crease of maybe 1. So this is a general number. But in Caucasians, we tend to think that the lid crease is about 8 to 10 in men and about 10 to 12 in women. So I think this is probably, of all the things I measure, this is the thing I pay most attention to, and that’s the levator function. We want to make sure that the muscle is working well. And if it’s not, that’s going to influence which surgical approach that we take. So here’s how we do that. We have a patient look down. I tend to say just look down at your knees or look down at your hands. But we want them to keep their head in a neutral position, because quite often I’ll say, I want you to look down at your hands, and they’ll put their head down like this. And I say, no, no, I want you to keep your chin up and just look down with your eyes. So I have them look down, and then I hold my little ruler so that I can see, I usually try to hold the zero mark on the edge he of their eyelid. And this is kind of what that looks like. And then I have them look up. Without moving the ruler, I want to see where the edge of the eyelid goes. So with good eyelid function, I’ll get 15 millimeters or more of movement. If it only goes up 3 or 4 millimeters, well, that’s poor levator function. And that’s going to be very important to help me determine what type of surgery I’m going to use to correct this. So again, I have them look down, and I hold the ruler, and then I have them look up. And I want to measure that distance or that eyelid excursion, how far up it goes. So this is an example of poor levator function. You can see we’re holding the child’s head in place. I’ll take some toy and I’ll move it down, hold the ruler, and move it up. And you can see in this child the right eyelid moves up nicely and the left eyelid really isn’t moving at all. Whereas in this girl, she has relatively good levator function. When she looks down, you can see the eyelid doesn’t look down on the left as much as the right. And when she looks up, you can see it doesn’t move up as high as it does on the right side. Now, one little trick that I was taught in my fellowship in children, when they’re asleep, you can usually tell which eye is the eye with ptosis, because it doesn’t close as well, and it doesn’t open as well. And this girl is a good example of that. Her — when she looks down, it doesn’t move down as far, and when she looks up, it doesn’t move up as far. So two very important things that you want to check here. You want to check for the opening of the eye like you see on the this gentleman on the left side, it’s not closing all the way. He probably has 3 to 4 millimeters of lagophthalmus. That can influence what sort of surgical approach you take, because you definitely don’t want to make a patient’s eyelid so open that they can’t close it and cover the cornea. And of course you also want to check for a Bell’s response. And that’s one of the things we see here, that he has an okay Bell’s response but not a great Bell’s response, because you can actually see the bottom of his cornea here. And again, that will definitely influence what type of surgery you do and the extent of the surgery that you do. So again, here are the key measurements. The MRD1 in a normal person is going to be about 4 millimeters. The MRD2 is going to be 5 or 6 millimeters. The interpalpebral fissure will be somewhere between 9 and 10. The margin to fold or margin to crease distance is going to be 8 to 12 in range. And the levator function is going to be about 15 millimeters in a very normal eyelid, and much less in someone that has a very weak levator muscle. And then we want to check for Bell’s and lag. And lastly, one of the things we always want to do when possible is to photograph our patients, because especially when you’re first starting out, when you’re learning how to do ptosis surgery, it’s hard to know how effective your surgery was if you don’t know what they look like to start with. And sometimes patients don’t know either. I’ve had patients that I did surgery on, and I thought, wow, that’s a fantastic outcome, they look perfect, and I show the patient in the mirror and they go, I don’t think it looks any different. Then I show them their preoperative photos and they’re like, wow, that is a big difference. So sometimes when the ptosis happens over 20 or 30 or 40 years, the lid droop is so slow, they don’t even notice it. So photography is really, really important when you’re — especially when you’re first starting out, to help you learn how good your technique is working to get the eyelid up to a normal position. Also, sometimes you do surgery on a patient, you have a great outcome, and then they come back in a couple of years and the eyelid is droopy again. And it’s good for you to be able to look back at your old pictures and say, okay, I had a good outcome from my surgery that I did, maybe the tendon was stretched again or broken again or the suture broke or something. So I encourage you to use your iPhone, or if you have a different type of camera, to take some pictures, both preoperatively and postoperatively. So now we’re going to move to surgical approaches. And Dr. Tooley is going to walk us through all the different things that we need to look at and the different approaches. Andrea? DR. ANDREA TOOLEY: Hi, everyone. I’m Andrea Tooley. Thank you, Dr. Pelton, and thank you, everyone, for being here. It’s been so great seeing just in the chat people from all over the world, so we’re very excited to have you here. We’re going to move into the surgical decisions for ptosis, levator resection or levator advancement is probably the most common kind of surgery we do for ptosis, especially in patients with good levator function. So for me, if their levator function is above 10 millimeters then usually I think they’re a good candidate for levator advancement or levator resection. Muller muscle-conjunctival resection, lots of people have had great results doing MMCRs for more ptosis. MMCR is an internal approach from the inside of the lid versus a levator which is an external approach. Then we’ll talk about a frontalis sling. Less than 8 millimeters, usually, for me, I’m performing a frontalis sling. Those are patients with congenital ptosis, or who have had a traumatic cause. Things that you want to consider during surgery are your types of anesthesia. In pediatric cases or patients who can’t tolerate surgery, you’ll want to do a general anesthesia. And with general anesthesia, you don’t have any intraoperative decisionmaking. You can’t ask the patient to open their eyes or evaluate the lids. So that’s something you need to take into consideration. For most adults we’re using just sedation. So a little relaxing medicine, but you can often perform these surgeries with only a local anesthesia, just right in the office, if you need to. Intraoperative lid height is very common to check and something that you want to check during surgery. I usually like to leave the lid right almost exactly where I want it to end up postoperatively or just a tiny bit higher. You can tend to overcorrect just a little and the lid will settle. Patients are often sedated. Some people talk about the effects of epinephrine, if you’ve used that in your local block. And so for me usually leaving the lid right where I want it tends to do well. Lots of people will sit the patient up and check the lid height during surgery to make sure that the lid height is symmetric. And then the last thing is very important, to protect the cornea, especially with frontalis slings, which can be really hard on the cornea especially with patients with preexisting dry eye. I always counsel my patients, if they have preexisting dry eye, that no matter what ptosis surgery we do, I expect their dry eye to get a little worse at the beginning, and usually the body adjusts. This is a video of a levator resection. So first we make our skin incision right at the lead crease. I tend to prefer a lower lid crease, because these incisions can raise over time, and I think erring on a lower crease looks more natural. We use monopolar cautery to get hemostasis. You can incise a small layer of orbicularis. We use a skin hook to pull that levator forward and opening the is septum. You can see that preaponeurotic fat pad, the fat over the levator muscle, and that’s a key landmark. You can do this with small scissors like a Westcott scissor or your cautery. Then we’re placing a permanent suture, here we’re using Prolene but you can also use silk. Across the tarsus. You want to have an intratarsal bite. Partial thickness through the tarsus. And then back up through the levator aponeurosis, to bring the levator down onto the tarsus. So you’re advancing the levator that has fallen back over time, you’re bringing it forward onto the tarsus again. And often one stitch is all you need. When I’m judging how far I want to pass it, I usually aim for that muscle aponeurosis junction. You can see the demarcation between the pink of the muscle and the white of the tendon or the aponeurosis. And that’s where I try to pass it initially. If you pass it too far up into the muscle, you get bleeding. Too low into the tendon, it might not be enough of the lift. The next procedure is the Muller muscle conjunctival resection. You can use an MMCR clamp, it can be very useful in the surgery. In an MMCR, we place a silk suture to help us evert the lid over a Demar retractor. We use a caliper and measure how much Muller’s muscle and conjunctiva we want to excise. Some people start with 8 millimeters, some people start with 9 millimeters. There’s different algorithms depending on how much ptosis you want to correct. I usually do around a 9-millimeter resection. So for that you would mark off 4.5 millimeter, half of that distance, into the conjunctiva. We’re using silk sutures here as traction sutures, nasal, central, and lateral. Then placing our clamp over that. You can remove the traction sutures once the clamp is in place. Now we’re taking an absorbable suture. You take your 15 blade and resect under underneath the clamp and you’ve removed that 8 or 9 millimeters of conjunctiva or Muller’s muscle. You close that conjunctiva up to that tarsal border. That’s good for hemostasis, it’s good for not leaving an open wound internally. And once you’ve run that stitch back, many people will externalize the suture so your knot can be tied externally and your knot doesn’t have to be on the inside of the lid where it may rub on the cornea. So here, this is Dr. Pelton operating, and he is tying that stitch externally. You can see him externalizing the needle. This is a double arm suture, that’s how he can do that. If you were using a single arm suture, you could start external first and internalize your suture and we cut it externally. So that’s our MMCR. For a frontalis suspension, there are multiple designs that you can use with your suspension material. You can do a simple triangle, a double, a pentagon. I like a double rhomboid. A pentagon or rhomboid are the most common shapes we see. The shape is determined by how we fix it over the tarsus and how we pass the spring material up to the brow. In a pentagon, we’ll have three points of fixation along the tarsus. So you’re taking your tarsus material, whether silicone sling, and you’re suturing it to the tarsus, nasal, central, and lateral. That gives you good contour and curvature and good elevation of the lidded. Then you’re passing your material in this pentagon shape up to the medial and lateral brow incision, and finally ending them both in the central incision where you tie the suture and you tie your sling material. So the actual knot ends up in the central incision and it’s buried in the central brow. It’s helpful to have some kind of shoehorn plate or a protector to put under the lid as you pass the sling material so that you don’t have a globe injury. This is a right needle which is a very helpful needle that has an eyelet at the tip where you can thread the sling material through that eyelet and it helps you make that pass from the tarsus to the brow. Here is an example, secured to the tarsal plate with silk sutures. It will be passed up into those brow incisions. Here is an example of Gore-tex that’s been used. This works very well too. There’s some other sling materials, some Aurosling and then the silicone sling is my personal favorite, it’s flexible, easy to adjust, and it’s inert and works very well if patients’ lids. So again, we make that lid incision. We fixate the sling material to tarsus. We pass the sling material up to the brow. We centralize it. And then we tie it off. So here is a video from Richard Allen who has made a lot of great oculoplastic videos, and we’ll see his techniques. Making that lid crease incision and then stab incisions at the brow. He makes his central incision a little bit higher. Using cautery to dissect out the tarsus and placing that stitch through the tarsal plate, again, partial thickness. He’s secured the sling material. And now using a big needle to pass it up to the brow incision and then into the central brow incision. He’s placed a sleeve on the sling material to bring it together instead of tying it in a knot. And then I think this is important, he’s placed three lid crease forming sutures. I think lid crease forming sutures are very helpful in congenital ptosis where there’s a poor lid crease and you’re at risk of getting prolapse of that preaponeurotic tissue if you don’t form the lid crease. So do some lid crease forming sutures and then you can close all of the external incisions. Things we want to think about postoperatively are contour and symmetry. I’ve found that small contour regularities in the very early post-op period tend to even out and smooth out over time. So I give people at least a month before having them do any kind of revision for contour. Corneal protection and lubrication, very important, especially in those patients with preexisting dry eye. The scar in the lid is so wonderful. It’s usually quite invisible and doesn’t need a lot of scar care other than some antibiotic ointment, we usually use something like a topical erythromycin ointment. Healing time and counseling. Some people might need a contact lens if they’re feeling very dry or have a lot of of postoperative lagophthalmus. I usually counsel patients to avoid eye makeup for a few weeks. Otherwise for postoperative care, it’s pretty simple. The most common complication that we see is asymmetry is over- and undercorrection, undercorrection being the most common. I tell my patients that sometimes eyelids just need a little extra oomph and they don’t respond the first time and that’s pretty normal. Lagophthalmus usually resolves. If it doesn’t, we can do a revision. Contact abnormalities tend to work themselves out but you could always do a revision if needed. Things like infection, hematoma, are fairly low risk and we see those quite infrequently. Recurrence is always a risk, and one of those things that just happens and you can deal with it if it happens. There are nonsurgical options for ptosis, if you have someone who is a very poor surgical candidate, maybe they’re in very poor health and can’t make it to the operating room or they have such terrible dry eye that you don’t want to worsen things by lifting the lid surgerically. We have ptosis glasses like these that actually work quite well. They have a little bar that push the eyelids back and they do elevate the lid. You can see in the side profile here how they’re pushing the lid back. That’s a nonsurgical option if you have a patient who is truly not a good surgical candidate. So in summary, just like Dr. Pelton said, accurate evaluation drives good outcomes. You want to match your surgical technique to levator function. Good function, 12 to 15 millimeters of levator function or more, do a levator resection. Slightly less function, you can try it but I counsel my patients that we’ll just have to see if their muscle performs. And 8 millimeters or less, I usually go to a frontalis. And always have a good discussion with your patients about risk and managing expectations. There’s lots of contributing factors. Brow ptosis can be a contributor. Mechanical function, how well their nerves or muscles are working, all of those things contribute to the results of your surgery. Here are the results of our poll questions. Most common are age-related levator dehiscence, that sunken appearance and significant ptosis. This ptosis I think the answer choices tricked us here, but this is a paralytic or neurogenic ptosis. So you can see a complete ptosis, and then when you elevate the lid, the eye is in abduction, the pupil is involved, this needs urgent evaluation to rule out third nerve palsy and any type of intracranial abnormality like Dr. Pelton said. And then the most common complication of ptosis surgery is undercorrection. I give my patients at least a month to make sure the eyes don’t settle. And then I usually bring them back for a revision. If you have clear under or overcorrection in the early postoperative phase, you can revise it earlier, but I try to let things settle for a bit because you would be surprised how well things can improve with some time. That concludes our ptosis overview. But it looks like we have lots of great questions in the chat. So thank you so much. I think we can open it to chat questions, if you think so too, Dr. Pelton. DR. RON PELTON: Yes, that would be great. DR. ANDREA TOOLEY: I’ll scroll up and we can start from the beginning. What is the role of optometrists in the management of ptosis, an interesting question. I think optometrists are invaluable for helping us screen and recognize ptosis, kind of like you said, Dr. Pelton, some patients night not even realize how severe their ptosis has gotten, and it’s often those optometrists that are saying, hey, you’re coming in with your chin up and holding your eyelids up, have you noticed that you have ptosis? Or they might be able to screen for some other underlying condition that’s more concerning, and then they can send them our way. DR. RON PELTON: I agree. Our optometry colleagues are very important, we think of them as being quite often on the front lines of eye evaluation. So I would say probably well more than half of the patients that come to see me with ptosis come from my optometry colleagues. DR. ANDREA TOOLEY: Thanks. Lovely. Next question. Which is more important, MRD or MFD, for surgical decision? Do you want to take that, Dr. Pelton? DR. RON PELTON: Well, I think it’s definitely MRD, because MFD or the margin to crease distance is going to vary great depending, again, on your race and on your sex. And so in my Asian patients, I will often see a one-millimeter lid crease but they still have levator dehiscence ptosis. So that’s not really going to affect which type of surgery I do. But it will affect how I do it. So MRD or how strong that muscle is, is definitely going to be the most important determinant on which type of surgery we’re going to choose. Do you agree? DR. ANDREA TOOLEY: Yes, I absolutely agree. One thing I’ve learned is that the MFD, that margin-fissure distance, or sometimes I call it the tarsal platform show, how much of that platform patients are seeing. Symmetry in that is very noticeable, and patients fixate on that. So even if the lids are actually in the same position, even if the MRD is symmetric between the two sides, if there are differences in the amount of tarsal platform show, that really bothers patients esthetically. And so sometimes I’ll take that into consideration, whether I need some crease formation sutures or I need to change the crease height during my surgery, because the eye can tolerate maybe subtle differences in MRD but I think if there’s differences in that tarsal platform, patients really notice it. DR. RON PELTON: Agreed. Also that’s very important, the MFD or the margin to crease or fissure distance is really something you want to pay attention to on congenital ptosis, especially if it’s unilateral. So you want to make sure that the side you’re operating on matches as closely as possible the normal side. So you really do want to pay attention to that. DR. ANDREA TOOLEY: Okay. Next question. What are the factors to consider when recommending surgical correction of ptosis, especially for congenital ptosis with good vision when the upper eye is pulled up? DR. RON PELTON: Well, you know, obviously we want — when possible, we want to work with our pediatric colleagues to make sure that the child doesn’t have amblyopia. If the child is developing amblyopia, that’s going to push us into operating at a sooner time than if the child doesn’t have amblyopia. I always try to wait until the child is at least a year old or older before I do surgery. But if we think that at 6:00 months the child as amblyopia or is developing amblyopia, that will push us to operate a little sooner. DR. ANDREA TOOLEY: I agree. If they have no amblyopia, if they’re doing well, if the lid is just a little low, I try to wait until maybe they’re six or seven, getting into school age, the face has developed a little more, the sinuses are starting to develop a little more. If that levator function is somewhere between 8 to 10, maybe even 7 to 10, sometimes I’ll try a levator resection before moving straight to a frontalis. DR. RON PELTON: Yeah, sometimes I tell the parents, if it’s pretty mild, I’ll say, let’s wait until it bothers the child. If I know they don’t have amblyopia. Because I find once children start to notice it in themselves, and especially around school time, when kids can be unkind and make fun of them, that’s often a good time to do it, because the child is motivated as well as the parents. DR. ANDREA TOOLEY: Agreed. Next question is, red flags in ptosis evaluation that should prompt urgent imaging. That’s a great question. I often look for anything out of the ordinary in terms of neurologic function. I always ask my patients about diplopia, make sure they don’t have double vision. You want to check that levator function, and if it’s not normal, then that’s something to consider. And also looking for if the pupils are symmetric. Those are the big three that I try to evaluate. DR. RON PELTON: In Colorado, one of the things we see is oculopharyngeal dystrophy. We’ll commonly ask patients about swallowing issues. If a patient comes in to see me and they have relatively advanced or profound ptosis and poor levator function, one of the first questions I’ll ask is do you have any problems swallowing. Quite often they’ll say, oh, yeah, I have to go in to see the GI doctors on a regular basis, and so does my sister, and my brother, and my mother. This then you know you’re dealing with something different. That’s also going to affect what type of surgical approach you take. DR. ANDREA TOOLEY: Great question. We’re getting a ton of questions. I don’t know if we should screen these at all or just try to keep moving on through. Could my meibomian glands get disrupted in surgery? Theoretically they should not be too affected in levator. There’s studies looking at the goblet cells of the conjunctiva and dry eye but I believe those results have been controversial. Some studies show it doesn’t do much, other studies show it does. I think in general there will be more evaporative dry eye because the eyes are more open, however you slice it. I counsel my patients to use extra lubrication. DR. RON PELTON: I suppose if in your surgery, like with the MMCR, the internal approach, I know some people will take a small bit of tarsus, superior tarsus, and I guess theoretically you could affect meibomian gland function. I haven’t seen that to be a big problem. Like Andrea, I take great care in patients who have preexisting dry eye to try and make sure that I don’t overcorrect too much and that we have a good, long discussion before surgery about what we’re — what the risks are of dry eye. What will make the prognosis good? The prognosis, if they don’t have amblyopia, that’s number one. And full two is their levator function. And one way to sort of get just a very quick evaluation of levator function is look at their lid crease. Patients that have very poor — you know, children that come in that have very poor levator function tend to have little or no lid crease. So when I see the mom holding the child and I see the child has a pretty decent lid fold then I know they probably have very good levator function. DR. ANDREA TOOLEY: Agreed. In the frontalis procedure, how do you get the material to the above brow point? Do you dissect from the lid or how do you pass them? That’s a great question. That’s where that needle comes in handy, either a right needle or I believe Dr. Allen has an Allen needle. But you can even use a free abdominal needle. But that long needle is what’s going to let you essentially take from the tarsus up to the brow point. So you don’t want to do a dissection, but you’re passing a needle in that big, long, one pass. DR. RON PELTON: So what’s the ideal surgery for synconedal ptosis? Some people talk about surgery on both sides, disinserting on one side and doing surgery on both sides like a sling. I’ve never done that. I don’t think that any of us have any good answer to that question. I know I don’t. What about you, Andrea? DR. ANDREA TOOLEY: No, I don’t either. I think any facial aberrancy is difficult to treat. If congenital ptosis, if there’s a jaw wink, I ignore the wink, that’s what I’ve been trained to do. In synconedal, I would probably try to improve the ptosis as much as I can and know there will be some fluctuation. >> Is the surgical technique the same in trauma cases? It depends on what kind of trauma it is, is the eyelid avulsed or does it just have a — I try to reestablish normal anatomy, try to find the bits of the eyelid and get them back where they’re supposed to be. Then one of the things that Andrea said earlier, I totally agree with, time is your friend. Tincture of time. Quite often if we simply wait, we can see eyelid improvement. But again, you don’t want to wait too long, because then it makes the surgery maybe a little bit harder. But you also don’t want to intervene too early. So like she said, I usually wait two or three or four weeks to kind of get an idea how things are going to do and then maybe jump back in. DR. ANDREA TOOLEY: There are a couple of questions about post procedural or post-traumatic ptosis. And in general, I wait at least six months, sometimes up to a year. If someone’s had a third nerve injury, facial trauma, they’ve had some other surgical procedure and they’ve come out with ptosis, I would say wait at least six months. I see the patient at about three-month intervals and measure changes in levator junctions, but six months to a year, you can see improvement before you do surgery. DR. RON PELTON: I agree. I had a patient who was having spine surgery, she had an incision on her neck and came in with a 2 millimeters of ptosis and a small pupil, that’s obviously a Horner’s syndrome. She wanted to know what surgery we could do to fix this. And I said, well, right now, nothing, because this may resolve on its own, it may just be due to blunt trauma or some swelling or whatever. So that’s one we’re waiting on. If they came in with no history of surgery or no history like that, like my neighbor did, and they have a Horner’s syndrome, I’m going to get imaging, because I’m worried about an aneurysm. Medical interventions for ptosis, really there’s something that we — that has come on the market here in the U.S., maybe all over the world, called Eupneic. It’s really the same thing as the medicine in Afra nasal spray, it’s oxymetazoline. Like Andrea was saying, she’ll see if the eyelid comes up, that’s one type of medical intervention, of course that dilates the eye, whereas the oxymetazoline doesn’t. That’s something that lasts about six to eight hours. You have to do it every day. There are patients who will do that, but it’s kind of expensive. Let’s see. How to tell the difference if a patient has mild ptosis of one eyelid versus mild lid retraction of the other eye. Well, one thing to do is pull up on the ptosis eyelid and see what happens to the other eyelid. If the other eyelid comes down, that kind of gives you your answer. DR. ANDREA TOOLEY: I totally agree. There were some questions about blood thinners. I like to have my patients off of things like aspirin or other antiplatelet medications for two weeks if at all possible. For novel anticoagulants, usually I have them off for about two days. And for Coumadin, I usually like an INR of around 1.5. I tell my patients that we can do the surgery on blood thinners, but it increases the risk of vision threatening bleeding, like a retro septal bleed, which would be bad, but also the more bleeding that you get in surgery, the more unpredictable your results, and if you do have quite a bit of swelling or hemorrhage postoperatively, I think that can stretch out your results too, and sometimes want lid ends up low. So if you cannot hold anticoagulants, you can still do the surgery, but I counsel my patients that the results are less predictable and the risks are slightly higher. DR. RON PELTON: Agreed. I often have — well, a lot of the patients that we do the surgery on are older. And here in the U.S., a lot of those guys are — have heart issues and so they’ll be on some sort of blood thinner. Quite often it’s just baby aspirin. But we actually have them sign a different consent form that, you know, acknowledges that I’m on a blood thinner and that that raises the risks. But you can see that with the surgery that we were doing there, the external approach, it’s a small incision, and I go very slowly with my cautery to make sure that any tiny little bleeder, I cauterize it quickly. How to improve skills in eyelid surgery in a dry-wet lab if we don’t have enough real life cases. Gosh. That’s a touch question. I’m not sure I have an answer to that, other than that I don’t know if you’re able to get some sort of animal head, because the eyelids in most animals like pigs, goats, et cetera, are pretty similar. They have a levator aponeurosis as well. But, you know, the real skills are the same skills you’re going to use doing almost any kind of eyelid surgery. Slow, controlled incisions, good hemostasis. Here the only issue is knowing your landmarks. Getting into — getting to the levator aponeurosis is fairly straightforward when you know your landmarks, just like, you know, getting to your home is fairly easy when you know the streets that you have to drive on. So that’s, I guess, a standard for any type of surgery, just know your anatomy. So maybe practice on some animal eyelids. If you have a cadaver lab, I think that’s a really good choice as well. DR. ANDREA TOOLEY: Yeah, I agree. These days there are so many fantastic videos online. So I would watch a ton of videos. DR. RON PELTON: Great. DR. ANDREA TOOLEY: As many as you can. For me, drawing things out helps me visualize. Then if I have a hard surgery, I always visualize it before. I close my eyes and I actually picture myself doing every step of the surgery from start to finish. And that has always really helped me. DR. RON PELTON: One of the questions that came up was about the frontalis flap surgery. And this is a surgery that I haven’t done, but I have a patient set up to do. I’ve watched videos online for hours. I’ve watched the same videos over and over and over. And let me just put in a little plug in for Dr. Richard Allen. That was one of the videos we looked at earlier. He has a whole library of great videos online. And he also has a Facebook page that you can follow and watches videos. And I strongly encourage you to watch those videos over and over and over, because he does a great job of narrating them. And most of them are only two or three minutes. DR. ANDREA TOOLEY: I agree. I’m just scrolling through. And we’re about at time. I’m not sure how much we should go over. But we are about at time. And it’s just been such a true pleasure to be here with everyone. DR. RON PELTON: Yes, and Andrea has a very strong online presence, so I encourage you to look her up and follow her. And I’m relatively easy to reach, also you can find me online. I’m not nearly as savvy as Dr. Tooley in my online presence, however I welcome any questions that any of you want to ask me. You can go and I encourage you to go through the Orbis Cybersight website. You can easily find me through that. And I would be more than happy to answer as many questions as you guys would like, or to look at your patients that you want to present. So I think with that, we have to get to seeing our patients. But I thank you very much for being with us today, and it’s, again, quite an honor to talk to such a large community. And just know that we appreciate you taking care of your patients. And we’re here to help any way we can.