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PALPEBRAL APERTURE with SPECIAL REFERENCE to the SURGICAL CORRECTION of PSEUDOPTOSIS by Rudolf Aebli, M.D.*

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PALPEBRAL APERTURE with SPECIAL REFERENCE to the SURGICAL CORRECTION of PSEUDOPTOSIS by Rudolf Aebli, M.D.* THE RELATIONSHIP OF PSEUDOPTOSIS TO MUSCLE TROPIAS AND THE PALPEBRAL APERTURE WITH SPECIAL REFERENCE TO THE SURGICAL CORRECTION OF PSEUDOPTOSIS BY Rudolf Aebli, M.D.* BERKE'S (1) DISSERTATION on blepharoptosis in 1945 and Spaeth's (2) on the same subject in 1946 were both so complete and so admirable in all respects that there would be no justification at this time for a duplication of their contributions. On the other hand, with the exception of Kirby's (3) paper, in 1940, on ptosis associated with loss of elevation of the eyeball, relatively little has been written on the subject of pseudoptosis caused by vertical muscle tropias. Almost nothing, furthermore, has been written on the relationship of the palpebral aperture to these anomalies. This contribution has a threefold purpose: (1) to explain this relationship; (2) to outline the correct diagnostic procedure in ptosis of the eyelid which results from anomalies of this kind; and (3) to set forth the best methods of treatment for them. ANATOMIC CONSIDERATIONS Before it is possible to discuss intelligently the clinical aspects of muscle tropias and the relationship of the palpebral aperture to them, certain important (albeit elementary) anatomic considera- tions must be briefly summarized. When the eyelids are in their normal relationship to the eye- ball, the margin of the upper lid lies midway between the limbus and the pupillary margin of the iris, while the margin of the lower lid is at the limbus. When the eyes are opened normally, the lids are separated from each other by an elliptical space, the palpebral From the Department of Ophthalmology, New York University Post Graduate Medical School, and the University and Lenox Hill Hospitals, New York City. 336 Rudolf Aebli fissure (aperture). This space measures, on the average, 27 mm. in the horizontal, and 9 mm. in the vertical, aspect. When the eyes are in the primary position, that is, when the gaze is directed straight forward, the relationship of the eyelids to the structures of the eyeball is scrupulously maintained as it has just been described. Similarly, the relationship which has been described is for the most part maintained when the gaze is directed up or down. Jameson (4), who places great emphasis upon this relationship, terms the harmonious interaction of the levator SaS'd~~~~~~~~ ~~~~~~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~ .. ............~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~...... A B C FIGURE 1. CONGENITAL PARALYSIS OF BOTH ELEVATORS OF LEFT EYE, WITH PSEUDOPTOSIS AND ALTERNATE FIXATION OF EYES A: When sound right eye fixes, left hypotropia is apparent, with marked ptosis of eyelid. B: When paretic left eye fixes, right eye is higher, sclera shows below at limbus, and cosmetic deformity is more pronounced. C: When both eyes are directed upward, paralysis of elevation of left eye is apparent, with secondary deviation of right inferior obllque. D-E: Postoperative result following operations on eyes consist- ing of resection of left superior rectus, with advancement to limbus, and recession (io mm.) of right inferior oblique by White technique. D: When right eye fixes, moderate left hypotropia is evident but ptosis of lid is slight; compare with A. E: When left eye fixes, upshoot of right eye is seen to have been corrected and sclera is no longer visible at limbus; compare with B. F: WAhen both eyes are directed to left, secondary deviation of right inferior oblique formerly present is no longer seen; compare with C. In this case the operative procedure will be completed by recession of the right superior rectus for 2-3 mm. Since the inferior oblique of this eye has been greatly weakened, special care will be taken at operation not to weaken the superior rectus excessively, there being grave danger under these circumstances of crippling the elevating power of the right eye. Relationship of Pseudoptosis to Muscle Tropias 337 muscles of the eyelid with the elevators and depressors of the eye- ball a striking phenomenon of perfect ocular adjustment. PATHOLOGIC PHYSIOLOGY In cases of disturbed ocular motility associated with hypotropia (a strabismus in which the axis of one eye deviates downward) or hypertropia (a strabismus in which the axis of one eye deviates upward), the lid normally follows the eye downward or upward, with the result that there is either a narrowing or a widening of the vertical dimension of the palpebral fissure (Fig. i). The picture D E F then presented, as White (5) has stressed, depends upon which eye fixates. If the sound eye fixes, the fellow eye is lower, the lid fol- lows the hypotropic eye downward (6), and the patient presents a picture of marked ptosis (Fig. iA). If, on the other hand, the paretic eye fixes, then the sound eye is higher, the lid follows the hypertropic eye upward, the palpebral aperture is widened, sclera is visible below at the limbus, and the cosmetic deformity is usually more marked (Fig. iB) than when the sound eye fixes It is well to remember in this connection, as Duane (7) has pointed out, that the deviating eye is not necessarily the paretic eye. CLASSIFICATION AND ETIOLOGY Ptosis of the eyelids (blepharoptosis) falls into two chief catego ries, true ptosis and pseudoptosis. True ptosis is caused by paralysis 338 Rudolf Aebli A B c FIGURE 2. ACQUIRED PTOSIS CAUSED BY MYASTHENIA GRAVIS A: Complete right-sided ptosis, forcing the patient to fix with the left (and poorer) eye. B: Condition of eyes 15 minutes after injection of prostigmine (gr. 1/40) and atropine sulfate (gr. 1/150). The patient can now open the (better) right eye and fix with it. The left eye is in a position of hypertropia, with widening of the pal- pebral fissure. C: Condition of eyes 30 minutes after prostigmine-atropine sulfate injection. In this case the ptosis and muscle imbalance were not apparent when the patient was well rested. When he was fatigued, the right lid drooped and closed. The degree of ptosis and tropia varied at different examinations and the measurements were not constant. A B c FIGURE 3. ACQUIRED PARTIAL PARALYSIS OF LEFT THIRD NERVE, WITH LEFT EXOTROPIA, LEFT HYPOTROPIA, AND PSEUDOPTOSIS The drooping lid and diverging left eye were first noticed 4 years ago, after an un- diagnosed febrile illness, the history of which suggested polioencephalitis. A: When patient fixes with right eye (her usual practice), left exotropia and left hypotropia and ptosis are evident. B: When she fixes with paretic left eye, secondary deviation of right external rectus is apparent. C: When eyes are directed upward and to left, weakness of superior rectus and secondary deviation of right inferior oblique are observed. Marked improvement followed recession of the secondarily contracted left inferior rectus and left external rectus, combined with resection of the paretic left superior rectus. of the levator muscle of the eyelid. A vertical muscle tropia is one of the frequent causes of pseudoptosis. Pseudoptosis and true ptosis may be either congenital or ac- quired. The congenital variety, which is frequently bilateral and which may be hereditary, may originate in an insertional, a structural, or an innervational, defect of a muscle or a group of muscles (8,9). Some cases are caused by birth trauma, the resultant local or central hemorrhages being followed, in their turn, by muscle fibrosis or atrophy. A B C D E F FIGURE 4. ACQUTIRED LEFT PARTIAL PARALYSIS OF THIRD NERVE IN 16-YEAR- OLD PATIENT, FOLLOWING POLIOENCEPHALITIS 10 YEARS EARLIER A: Fixation of left eye in upper temporal quadrant, as result of extreme secondary contractures of left external recttus and left superior rectus. Left lid follows hyper- tropic eye upward. Palpcbral fissure is markedly widenedl and sclera is visible below at limbus. B: WVhen gaze is directed straight ahead, left eye is immobile and fixed in upper temporal qtuadIrant. C: XVhen eyes are directed to right, left eye is fixed in upper temporal quiadrant. D-F: Postoperative result following operation on all four left recti muiscles tin(er local analgesia at single sitting. The left external rectus, wllich was tense, tauit, an(l secon(larily contracted, was recesse(l to the equator. The left superior recttus, the con(lition of which was similar, was recessed 5 mm. The left internal recttus, wlhich was flabby an(l atrophic, was resecte(l 8 mm. and advanced to the limbus. The left inferior rectus, the condition of which was similar, was also resected 8 mm. D: Postoperative appearance with eyes directed to left; compare with A. E: Postoperative appearance with eyes directed straight ahead; compare with B. F: P'ostoperative appearance with eyes (lirected to right; compare with C. In this case, as in all instances of partial third nerve paralysis, the position of the globe and of the lid varicd. In all stuch cases the position (lepends upon the extent and degree of nerve involvement and upon the amount of secondlary contracture which develops. These illutstrations should be compare(l with figure 3. In that case the left superior rectuis was more markedly paretic and the left inferior rectus (the direct antagonist) hda(ldeveloped a secondary contractuire with the passage of time, with resuiltant left hypotropia, psetidoptosis and narrowing of the fissure. In this case over a period of io years, the left external recttus and left superior rectus had developed a marked secon(ldary contracture, with widening of the palpebral fissure and disfiguring left hypertropia, the sclera being visible at the lower limbus. A B C FIGURE 5. UNILATERAL RETRACTION SYNDRO-ME, WITH LEFT PSEUDOPTOSIS CAUSED BY SPASMODI)C CONTRACTION OF ORBICUT,ARIS MUSCLE A: WVhen patient fixes with right eye, left palpebral fissure is narrowed, globe on this side is retracted, and spasm-tiodic contraction of left orbictilaris is evident.
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