Ptosis classification in children and adults and treatment modalities

Ptoza je medicinski izraz za spuštenu gornju očnu vjeđu ispod uobičajene razine pri pogledu prema naprijed. Vrijeme nastanka, kao i uzroci, mogu biti različiti, no danas postoje dvije klasifikacije koje znatno olakšavaju njihovo svrstavanje i prema tome određuje liječenje. S obzirom na vremensku komponentu, postoje kongenitalne i stečene ptoze, dok se prema uzroku dijele na miogene, aponeurotske, neurogene, mehaničke i traumatske. Najčešći razlog kongenitalne ptoze jest slabiji razvoj mišića podizača vjeđe (miogeni tip), a u stečene ptoze najčešći razlog nastanka jest istezanje i/ili dezinsercija aponeuroze mišića podizača vjeđe (aponeurotski tip). Kongenitalna ptoza prisutna je po rođenju ili neposredno nakon njega, s većom zahvaćenošću samo jednog oka i to obično lijevog. Stečena pak, kako joj samo ime nalaže, može nastati u bilo kojem drugom trenutku života. Simptomi variraju ovisno o podlozi same ptoze, no u one česte spada reverzibilni gubitak perifernog vida, posebno gornjeg vidnog polja. Ljudi se osim toga žale na teškoće u čitanju koje se pogoršavaju pri čitanju prema dolje. Pretpostavlja se da to nastaje zbog relaksacije frontalnog mišića u tom položaju, dok u primarnom položaju maskira težinu ptoze. Zbog premale količine svjetla koja dopire do makule, može se smanjiti vidna oštrina, osobito noću. Osim navedenog, susreću se i refrakterne greške, slabovidnost, abnormalnosti zjenice, disfunkcija vanjskih očnih mišića i slično. Uz anamnezu, izrazito je bitan klinički pregled sastavljen od četiriju neizostavnih mjerenja (funkcija levatora (FL), marginal-reflex distance (MRD), visina palpebralne fisure te pozicija nabora gornje vjeđe), a služi za utvrđivanje parametara neophodnih za planiranje daljnjeg liječenja (stupanj težine ptoze i FL). Ptoza se liječi konzervativno i kirurški. Konzervativni pristup je nešto neuobičajeniji način liječenja, a sastoji se od opservacije do sredstava koja stabiliziraju vjeđu za supraorbitalne strukture. Kirurški pristup češće je biran model liječenja. Razne su vrste takvog liječenja, a temelje se na preoperativnoj kliničkoj evaluaciji funkcije mišića podizača vjeđe i položaju vjeđe u primarnom položaju. Ugrubo se dijele na suspenzijske operacije koje koriste okolnu muskulaturu kao pomoć pri podizanju vjeđe te operacije koje se izvode direktno na mišiću podizaču gornje vjeđe. Niti jedna metoda nije superiorna u odnosu na drugu te se individualno odabire prema potrebama bolesnika i preferencijama kirurga nakon opsežne preoperativne procjene. Komplikacije su moguće, a najčešće od njih su hipo- i hiperkorekcija ptoze, lagoftalmus uz posljedičnu izloženost rožnice i krvarenje kao prolazna komplikacija. Prognoza je uglavnom dobra, a ovisi o uzroku ptoze, njezinoj težini, odabiru kirurške metode i samoj vještini kirurga.Blepharoptosis is a medical term for drooped or fallen upper eyelid, under usual level while looking forward. The time of occurrence as well as the causes can vary. Today, severe known classifications considerably ease their assortment and accordingly determine the curative treatment. Considering the time component, there is congenital and acquired ptosis. According to the cause, there is myogenic, aponeurotic, neurogenic, mechanical, and traumatic ptosis. The most common cause of congenital ptosis is a weak development of the levator muscle (myogenic type), and due to an acquired ptosis there are strain and disinsertion of the aponeurosis in the same muscle (aponeurotic type). Congenital ptosis is present at birth or just after it, with a greater involvement of just one eye and usually left. Acquired ptosis, just as its name implies, can arise at any other moment of life. Symptoms vary depending on the background of the ptosis itself, but commonly there is reversible loss of peripheral vision, especially the upper visual field. People also complain of reading difficulties that are getting worse while reading by looking down. A hypothesis says it´s happening due to the relaxation of the frontal muscle in that position, while in the primary position it masks the weight of the ptosis. Because of the low volume of light reaching the macula, visual acuity may be reduced, especially at night. In addition to this, there are also refractive errors, amblyopia, pupil abnormality, external eye muscle dysfunction, etc. Along with medical history, what is extremely important is proper clinical exam consisting of four indispensable measurements (levator function (FL), marginal-reflex distance (MRD), vertical interpalpebral fissure height and upper eyelid crease position), and it serves to determine the parameters necessary for planning further treatment (ptosis degree and FL). Ptosis is treated conservatively and surgically. Conservative approach is a somewhat obscure method of treatment, including observation and remedies that stabilize the eyelid for supraorbital structures. Surgical approach is more often a chosen model of treatment. Various types of such treatment are based on preoperative clinical evaluation of the levator muscle function and eyelid position in primary gaze. They are rougly split into suspensive surgeries that use the surrounding musculature as a help in lifting the eyelid and into those performed directly on the muscles of the upper eyelid. None of the methods are superior to the others, and each method is individually selected according to the patient`s needs and the surgeon´s preferences after extensive pre-operative assessment. Complications are possible, and most often we see hypo- and hypercorrection of the ptosis, lagophtalmos with consequent corneal exposure, bleeding etc. The prognosis is generally good, depending on the cause of the ptosis, its weight, the choice of surgical methods and the surgeon´s own skill