Upper Lid PtosisEa RaksmeyFirst Year Resident
Outline• Definition• Classification• Measurements• Diagnosis• Differential Diagnosis• Management
Definition• Blepharoptosis or eye lid ptosis is an abnormally
low position of the upper eye lid
Classification• Causes:• Congenital • Acquired
• Mechanisms:• Neurogenic• Myogenic• Aponeurotic • Mechanical
MeasurementsMargin-reflex distance (MRD)• MRD1: distance
between upper lid margin and CLR. N: 4-4,5 mm• MRD2: distance
between lower lid margin and CLR. N: 5-5,5 mm
Measurements Palpebral fissure height•Distance between upper and lower lid margin•Normal:–Women: 8-12 mm–Men: 7-10 mm
•Upper lid: 2mm below sup. limbus •Lower lid: 1mm above inf. Limbus
Measurements Levator function•Place thumb against brow to stop frontalis •Patient look down•Then look up •Measure with a ruler •Results:
– >15mm: normal– 12-14 mm: good– 5-11 mm: fair– <4 mm: poor
MeasurementsUpper eye lid crease•Veritcal margin of lid crease and lid margin in downgaze •Normal:
– Women: 10 mm– Men: 8 mm
MeasurementsLagophthalmos•Inability to close eye lids completely•7th nerve palsy
Neurogenic PtosisCongenital ptosis •CN III palsy
– Ptosis + inability to elevate, depress and adduct globe
•Congenital Horner syndrome– Miosis, anhidrosis, decrease pigmentation of iris
•Marcus Gunn jaw-winking syndrome– Unilateral ptosis, elevated with jaw movements
Neurogenic PtosisMarcus Gunn jaw-winking Sd
Horner Sd
Neurogenic PtosisAcquired ptosis•CN III palsy
– Ischemic or compressive– Pupil or non-pupil involved
•MG– Ptosis worsens with fatigue– Eye fatigability test– Ice pack test – Acetylcholine receptor AB test
Myogenic PtosisCongenital ptosis•Malformation of levator muscle•Fibrous and adipose tissue replace muscle •Signs:
– Decrease levator function– Eye lid lag– Lagophthalmos – Upper lid crease absent or poorly formed– Downgaze ptotic eye lid higher than fellow eye
Myogenic Ptosis
MRD1RE: 5 mmLE: 1 mm
Upgaze accentuate ptosis
Downgaze lid lag
Myogenic PtosisAcquired Ptosis•Localized or diffuse muscular dystrophy•Chronic progressive external ophthalmoplegia•MG•Oculopharyngeal dystrophy
Aponeurotic Ptosis• Involutional attenuation• Repetitive traction (rubbing, contact lenses,
surgery)• Signs: • High or absent upper lid crease• Thinning of eye lid• Good levator function• Worsen in downgaze
Aponeurotic Ptosis
Good levator function
Eye lid drop in downgaze
RE aponeurotic ptosis after cataract surgery
Mechanical PtosisCogenital ptosis•Plexiform neuroma•Hemangioma Acquired ptosis•Chalazion•Skin carcinoma•Lid masses•Trauma
Differential DiagnosisPseudoptosis•Lack of support (artificial eye, microophthalmos…)•Controlateral lid retraction•Ipsilateral hypotropia•Brow ptosis•Dermatochalasis
Brow ptosis Lid retraction Ipsilateral hypotropia
Management• Non surgical:• Eye lid crutches• Treat causes of mechanical ptosis
• Surgical:• External (transcutaneous) levator advancement• Internal (transconjunctival) levator/tarsus/Müller
resection• Fronatlis muscle suspension
External Levator Advancemnt• Indications• Levator function
normal• Lid crease is high
Internal Levator/Tarsus/Müller resction
Frontalis muscle suspension • Indications:• Severe ptosis (>4mm) poor levator function (<4mm)• Marcus Gunn• Blepharophimosis • CN III palsy• Unsatisfactory result from previous levator resection
Frontalis muscle suspension
A. Site of incision markedB. Threading of fascia lata
stripC. Tightening and tying of
strip
Surgery