PTOSIS Types,causes,examination,treatment

1. PTOSIS
SATISH REDDY A.N
4127

2. OBJECTIVES
1.DEFINITION
2.TYPES
3.EXAMINATION
4.TREATMENT

3. DEFINITION
Abnormal drooping of upper eyelid is
called ptosis.
Normally upper eyelid covers 1/6th of
cornea i.e. 2mm.
Therefore, in ptosis it covers >2mm

4. TYPES
1.CONGENITAL PTOSIS
• Simple congenital ptosis
• Blepharophimosis syndrome
• Marcus Gunn jaw winking
ptosis (congenital synkinetic
ptosis)

5. Simple congenital ptosis
• Developmental dystrophy of levator muscle
• Occasionally associated with weakness of superior rectus
Frequent absence of upper lid crease
Usually poor levator function

6. Blepharophimosis syndrome
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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)
Poorly developed nasal bridge
and hypoplasia of superior orbital
rims

7. Marcus Gunn jaw-winking syndrome
• Accounts for about 5% of all cases of congenital ptosis
• Retraction or ‘wink’ of ptotic lid in conjunction with
stimulation of ipsilateral pterygoid muscles
Opening of mouth
Contralateral movement of jaw

8. 2.ACQUIRED PTOSIS
•Neurogenic ptosis
•Myogenic ptosis
• Aponeurotic
ptosis
•Mechanical ptosis

9. Horner syndrome(neurogenic)
•
Caused by oculosympathetic
palsy
•
Usually unilateral mild
ptosis and miosis
•
Normal pupillary reactions
ptosis (paralysis of Muller’s
muscle)

10. third nerve palsy(neurogenic)
Severe unilateral ptosis and
defective adduction
Defective elevation
Normal abduction
Defective depression

11. Ocular myasthenia(myogenic)
Ptosis
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bilateral but asymmetrical
Worse with fatigue and in upgaze
Diplopia
•
Intermittent and usually vertical

12. Aponeurotic ptosis
Weakness of levator aponeurosis
• Causes - involutional, postoperative and blepharochalasis
•
Mild
High upper lid crease
Severe
Deep sulcus

13. Mechanical ptosis
Due to excessive weight on upper lid
Causes
Dermatochalasis
Severe lid oedema
Large tumours
Anterior orbital lesions

14. EXAMINATION
• EVALUATION
Pseudoptosis
Trueptosis
• Measurement of degree of
ptosis
• Margin reflex distance (MRD)
• Assessment of levator function
• Special investigations (Tests)

15. Causes of pseudoptosis
Lack of lid support
Ipsilateral hypotropia
Contralateral lid retraction
Brow ptosis - excessive
eyebrow skin
Dermatochalasis - excessive
eyelid skin

16. Marginal reflex distance
• Distance between upper lid
margin and light reflex (MRD)
• Mild ptosis (2 mm of droop)
• Moderate ptosis (3 mm)
• Severe ptosis (4 mm or more)

17. Edrophonium test (tensilon test)
Before injection
•
Measure amount of ptosis or
diplopia before injection
Positive result
Inject i.v. test dose of edrophonium
• Inject remaining dose if no hypersensitivity
MYASTHENIA GRAVIS(paradoxical reversal)
•

18. TREATMENT
Congenital ptosis- Almost always surgical treatment
Acquired ptosis-Treat the underlying cause 
SURGERY
1.Fasanella servant operation
2.Levator resection
3.Frontalis sling operation

19. Fasanella-Servat procedure
Indicated for mild ptosis(1.5-2mm) with good levator function
..
Excision of upper border of tarsus, lower border of Muller muscle
and overlying conjunctiva

20. Levator resection
Indicated for any ptosis provided levator function is at least 5 mm
Contraindicated in patients having severe ptosis with poor levator function
Shortening of levator complex
Amount determined by levator
function and severity of ptosis

21. Frontalis brow suspension
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Main indications
Severe ptosis with poor levator function ( 4 mm or less )
Marcus Gunn jaw-winking syndrome
Attachment of tarsus to frontalis muscle with
sling