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Dr. Christina Samuel
Postgraduate Ophthalmology
MMCH & RI
OBJECTIVES DEFINITION
TYPES
EXAMINATION
TREATMENT
DEFINITION Abnormal drooping of upper eyelids is called ptosis
Normally upper eyelid covers 1/6th of cornea ie,. 2mm
Therefore in ptosis it covers more than 2mm
TYPES OF PTOSIS 1.CONGENITAL PTOSIS
#simple congenital ptosis
#blepharophimosis syndrome
#marcus gunn jaw winking ptosis(congenital synkinetic ptosis)
2.ACQUIRED PTOSIS
#neurogenic ptosis
#myogenic ptosis
#aponeurotic ptosis
#mechanical ptosis
CLASSIFICATION OF PTOSIS
• Third nerve palsy1. Neurogenic
• Third nerve misdirection
• Horner syndrome
• Marcus Gunn jaw-winking syndrome
• Myasthenia gravis
• Myotonic dystrophy
• Ocular myopathies
• Simple congenital
2. Myogenic
3. Aponeurotic
4. Mechanical
• Blepharophimosis syndrome
Simple congenital ptosis• Developmental dystrophy of levator muscle
• Occasionally associated with weakness of superior rectus
Unilateral or bilateral ptosis of varying severity
In downgaze ptotic eyelid is slightly higher
Frequent absence of upper lid crease Usually poor levator function
Blepharophimosis syndrome
• Rare congenital disorder
• Dominant inheritance
• Moderate to severe symmetrical ptosis
• Short horizontal palpebral aperture• Telecanthus (lateral displacement
of medial canthus)• Epicanthus inversus (lower lid
fold larger than upper)• Lateral inferior ectropion• Poorly developed nasal bridge
and hypoplasia of superior orbitalrims
Marcus Gunn jaw-winking syndrome• Accounts for about 5% of all cases of congenital ptosis
• Retraction or ‘wink’ of ptotic lid in conjunction withstimulation of ipsilateral pterygoid muscles
Opening of mouth Contralateral movement of jaw
Left third nerve palsy
Severe unilateral ptosis anddefective adduction Normal abduction
Defective elevation Defective depression
Bell’s phenomenonUpward rotation of globe on lid closure
Good Poor - risk of postoperativecorneal exposure
Right third nerve misdirection• Rare, unilateral
• Aberrant regeneration following acquired third nerve palsy
• Pupil is occasionally involved
• Bizarre movements of upper lid accompany eye movements
Right ptosis in primaryposition
Worse on right gaze Normal on left gaze
Horner syndrome
• Caused by oculosympatheticpalsy
• Usually unilateral mildptosis and miosis
• Slight elevation of lower lid
• Normal pupillary reactions
• Iris hypochromia ifcongenital or longstanding
• Anhydrosis if lesion is belowsuperior cervical ganglion
Important causes of Horner syndromeCentral(first order neurone)
• Brainstem disease(vascular, demyelination)
• Spinal cord disease(syringomyelia, tumours)
Pre-ganglionic(second order neurone)
• Intrathoracic lesions(Pancoast tumour, aneurysm)
• Neck lesions(glands, trauma)
Post-ganglionic(third order neurone)
• Internal carotid artery disease
• Cavernous sinus mass
Posterior hypothalamus
Ciliospinal centre of Budge( C8 - T2 )
Superior cervicalganglion
Myasthenia Gravis
• Uncommon, typically affects young women1 Clinical features.
• Edrophonium (Camiston) test
2. Investigations
• Medical - anticholinesterases, steroids and azathioprine
3. Treatment options
• Weakness and fatiguability of voluntary musculature
• Three types - ocular, bulbar and generalized
• Antibodies to acetylcholine receptors
• CT or MRI for presence of thymoma
• Electromyography to confirm fatigue
• Thymectomy
Ocular myasthenia
• Insidious, bilateral but asymmetrical
• Worse with fatigue and in upgaze
Ptosis
• Ptotic lid may show ‘twitch’ and‘hop’ signs
• Intermittent and usually vertical
Diplopia
Myotonic dystrophy
Facial weakness and ptosis
• Involvement of tongue and pharyngeal muscles
• Ophthalmoplegia - uncommon
• Muscle wasting • Hypogonadism
• Frontal baldness in males
• Intellectual deterioration
• Presenile stellate cataracts
Release of grip difficult
Ocular myopathies
• Isolated
• Oculopharyngeal dystrophy
• Kearns-Sayre syndrome(pigmentary retinopathy)
• Ptosis - slowly progressive and symmetrical
• Ophthalmoplegia - slowlyprogressive and symmetrical(no diplopia)
Clinical types Ocular features
Aponeurotic ptosis• Weakness of levator aponeurosis• Causes - involutional, postoperative and blepharochalasis
High upper lid crease Good levator function
Absent upper lid crease Deep sulcus
Mild
Severe
Mechanical ptosis
Causes
Dermatochalasis Large tumours
Severe lid oedema Anterior orbital lesions
Causes of pseudoptosis
Ipsilateral hypotropia Brow ptosis - excessiveeyebrow skin
Dermatochalasis - excessiveeyelid skin
Lack of lid support Contralateral lid retraction
Marginal reflex distance
• Distance between upper lidmargin and light reflex (MRD)
• Mild ptosis (2 mm of droop)
• Moderate ptosis (3 mm)
• Severe ptosis (4 mm or more)
• Reflects levator function
• Normal (15 mm or more)
• Good (12 mm or more)
• Fair (5-11 mm)
Upper lid excursion
• Poor (4 mm or less)
• Distance between upper and lower lid margins
• Normal upper lid margin rests about 2 mm below upper limbus
• Normal lower lid margin rests 1 mm above lower limbus
• Amount of unilateral ptosis is determined by comparison
Vertical fissure height
Upper lid crease
• Distance between lid margin and lid crease in down-gaze
• Normals - females 10 mm; males 8 mm
• Absence in congenital ptosis indicatespoor levator function
• High crease suggests an aponeuroticdefect
• Distance between lash line and skin fold in primary position of gaze
Pretarsal show
crease fold
Edrophonium test
• Measure amount of ptosis or diplopia before injection
• Inject i.v. atropine 0.3 mg
• Inject i.v. test dose of edrophonium (0.2 ml-2 mg)
• Inject remaining (0.8 ml-8 mg) if no hypersensitivity
Before injection Positive result
Fasanella-Servat procedure
Excision of upper border of tarsus, lower border of Muller muscle and overlying conjunctiva
Indicated for mild ptosis with good levator function
..
Levator resection
Shortening of levator complex
Indicated for any ptosis provided levator function is at least 5 mm
Amount determined by levator function and severity of ptosis
Frontalis brow suspension
Attachment of tarsus to frontalis muscle with sling
Main indications
• Severe ptosis with poor levator function ( 4 mm or less )
• Marcus Gunn jaw-winking syndrome
THANK U