PTOSISBY BRAHAMDEV MANDAL

SECOND YEAR B.OPTOM GUIDED BY DR GAURANG MAKAVANAHARIJYOT COLLEGE OF OPTOMETRY

INTRODUCTION

ABNORAMAL DROOPING OF THE UPPER EYELID

UPPER EYELID COVERS ABOUT UPPER ONE –SIXTH OF THE CORNEA .i.e., ABOUT 2 mm.

THEREFORE, IN PTOSIS IT COVERS MORE THAN 2mm.

TYPES (1) CONGENITAL

(2)ACQUIRED: ( a) Neurogenic ptosis (b) Myogenic ptosis (c) Aponeurotic ptosis (d) Mechanical ptosis

CONGENITAL (1) simple congenital ptosis (not associated with any anomaly)

(2) congenital ptosis with associated weakness of superior rectus muscle.

(3) As part of blepharophimosis syndrome, which comprises congenital ptosis ,blepharophimosis ,telecanthus and epicanthus inversus. (4)Congenital synkinetic ptosis (Marcus Gunn Jaw –winking ptosis)

Fig. Congenital ptosis

(A)simple (B) blepharophimosis syndrome

Acquired ptosis(1) NEROGENIC PTOSIS

caused by innovational defects such as third nerve palsy, Horner’ syndrome, ophthalmoplegic migraine and multiple sclerosis

Horner’s syndrome, is due to oculosympathetic paresis is characterized by

(1) mild ptosis(due to paralysis of Muller’s muscles)

(2) miosis (due to paralysis of dilator pupillae) (3) Anhydrosis (reduced ipsilateral sweating ) (4) mild enophthalmos (5) loss of ciliospinal reflex

Fig NEROGENIC PTOSIS

(2) Myogenic

occurs due to acquired disorders of the LPS muscle or myoneural junction.

Seen in patients with myasthenia gravis, dystropia myotonica,ocular myopathy.

Fig: MYOGENIC PTOSIS

(3) Aponeurotic ptosis

It develops due to defects of the levator aponeurosis in the presence of a normal functioning muscle .It includes;

(1) Involutional (senile ) ptosis

(2) postoperative ptosis (which is rarely observed after cataract and retinal detachment surgery )

(3) ptosis due to aponeurotic weakness associated with blepharochalasis and

(4) Traumatic dehiscence or disinsertion of the aponeurosis.

Mechanical ptosis

Result due to excessive weight on the upper lid as seen in patients with lid tumors, multiple chalazia and lid oedema.

May occur due to scarring (cicatricial ptosis) as seen in patients with ocular pemphigoid and trachoma

CLINICAL EVALUTION (1) HISTORY: It should include age onset ,family history ,history

of trauma ,eye surgery and variability in degree of the ptosis.

(2) EXAMINATION: (a) Exclude pseudoptosis(stimulated ptosis) on

inspection . Its common causes are: Ipsilateral conditions such as

microphthalmos, phthisis bulbi , enophthalmos ,hypotropia

Contralateral condition include: eyelid retraction ,high myopia and proptosis.

(2) OBSERVE THE FOLLOING POINTS IN EACH CASE:

(a) Whether ptosis is unilateral or bilateral. (b) Function of orbicularis oculi muscle. (c) Eyelid crease is present or absent. (d) Jaw –winking phenomenon is present or not. (e) Associated weakness of any extraocular muscle. (f) Bell’s phenomenon(up and outrolling of the eyeball during forceful closure) is present or not

BELL’S PHENOMENON

(3) MEASUREMENT OF AMOUNT(DEGREE) OF PTOSIS:

(a) In case of unilateral ,difference between the vertical height of the palpebral fissure of two sides indicates the degree of ptosis.

(b) In bilateral cases it can be determined by measuring the amount of cornea

covered by the upper lid and then subtracting 2 mm .Ptosis is graded depending upon its amount as: Mild ptosis = 2mm Moderate ptosis = 3mm Several ptosis = 4mm

Fig measurement of amount of ptosis

(4) MARGIN REFLEX DISTANCE (MRD) REFERS TO THE the distance between the upper lid margins and corneal light reflex (of a pen torch held in front , on which patient is looking ) Normal value of MRD IS-5mm.

(5) ASSESMENT OF LEVATOR FUNCTION: It is determined by lid excursion caused by LPS muscle(Burke’s method ) . Patient is asked to look down , and thumb of one hand is placed firmly against the eyebrow of the patient( to block the action of frontalis muscle )by the examiner. Then the patient is asked to look up and the amount of upper lid excursion is measured with a ruler held in the other hand by examiner. Levator function is graded as follows: Normal : 15mm Good : 8mm or more Fair : 5-7 mm poor : 4mm or less

6 SPECIAL INVESTIGATIONS:(1) Tensilon test : Is performed when myasthenia is suspected.

(2) Phenylephrine test : Is carried out in patients suspected of Horner’s

syndrome.

(3) Neurological investigations May be required to find out the cause in patient

with neurogenic ptosis

(7) PHOTOGRAPHIC RECORD

Of the patient should be maintained for comparison .

Photographs should be taken in primary position as well as in up and down gazes.

TREATMENT (1) CONGENITAL PTOSIS Always needs surgical correction .

In several ptosis , surgery should be performed at earliest to prevent stimulus deprivation amblyopia.

In mild and moderate ptosis, surgery should be delayed until the age of 3-4,when accurate measurements are possible.

can be treated by any of the following operations:

(A) Tarso-conunctivo-Mullerctomy (Fasanella-Servat operation):

It is performed in cases having mild ptosis(1.5-2mm) and good levator function .

In it ,upper lid is everted and the upper tarsal border along with its attached Muller’s muscle and conjunctiva are resected.

(B) Levator resection:

Performed operation for moderate and several grade of ptosis.

It is contraindicated in patients having several ptosis with poor leavator function.

(C) Frontalis sling operation (Brow

suspension):

Performed in patients having severe ptosis with no levator function: (2) Acquired ptosis (a) Treat the underlying cause where ever possible.

(b) Conservative treatment should be carried out and surgery deferred treatment at least for 6 months in neurogenic ptosis.

(c) Surgical procedure (when required)