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