Ptosis is known as the drooping of the upper eyelid, and the patient usually presents with the complaint of the defect in vision and cosmesis. It can be congenital or acquired, or it can be neurogenic, myogenic, aponeurotic, mechanical, or traumatic in origin.
3. CAUSES
1. Neurogenic
Caused by an innervational defect e.g.
3rd Nerve paresis.
Horners Syndrome (oculosympathetic palsy).
2. Myogenic
Caused by myopathy of levator muscle it self
Impairment of impulses at neuromuscular junction(Neuromyopathic
cause).
NOTE
Acquired myogenic Ptosis occurs in
Myasthenia gravis
Myotonic Dystrophy
Progressive External Ophthamoplegia
4. CAUSES Cont”d
3. Aponeurotic
Caused by defect in levator aponeurosis.
4. Mechanical
May occur due to the following.
Scarring.
Gravitational effect of a mass.
5. CLINICAL EVALUATION OF PTOSIS
1. History
Age at onset of ptosis.
Duration of ptosis
If history is not clear, check old photos.
Ask about symptoms of possible underlying
systemic disease e.g.
Associated diplopia.
Variability of Ptosis during the day and in
presence of excessive fatigue.
6. PSEUDO PTOSIS
Rule out possible causes of pseudo ptosis.
a) Lack of support of the lids by the globe leads to orbital volume deficit.
Found in following conditions
Artificial eye
Microphthalmos
Phthisis bulbi.
Enophthalmos
b) Contralateral Lid Retraction
Compare the levels of upper lid margins.
NOTE
Normal upper lid margin covers 2mm of superior cornea
c) Ipsilateral Hypotropia
Causes pseudoptosis because upper lid follows the globe in down gaze
12. PTOSIS MEASUREMENTS
1 Margin-Reflex distance (MRD)
Distance between the upper lid margin and corneal reflection
of pen torch held by examiner.
Normal 4-4.5mm
2. Palpebral Fissure Height
Distance between upper and lower lid margins.
Normal Males 7-10mm
Females 8-12mm
Ptosis Grade
2mm-mild 3mm-moderate 4mm-severe
15. MEASUREMENTS Cont”d
3. Levator Function (Upper lid excursion)
Place thumb firmly against patients brow to negate action of
frontalis muscle with eyes in down gaze.
Patient then looks up as far as possible.
Amount of excursion is measured with a rule.
Normal-up to 15mm
Good 12-14mm
Fair 5-11mm
Poor 4mm or less
17. MEASUREMENT Cont”d
4. Upper Lid Crease
Vertical distance between the lid margin and lid crease in
down gaze.
Normal Female-10mm Male 8mm.
NOTE
Absence of crease in a case of congenital Ptosis suggests
poor levator function.
High crease suggests an aponeurotic defect.
5 Pretarsal show.
Distance between the lid margin and skin with eyes in
primary position
18. ASSOCIATED SIGNS cont”d
4. Jaw- winking Phenomenon
Ask patient to chew and move the jaws from side to side.
5. Bells Phenomenon
Manually hold the lid open, asking the patient to try to shut
his eyes and observe upward and outward rotation of the
globe.
NOTE
Weak Bells Phenomenon has risk of post operative exposure
keratitis.
21. TYPES OF PTOSIS
1. Simple Congenital Ptosis
a) Pathogenesis
Failure of nerve migration or development with
muscular sequelae
b) Signs
Unilateral or bilateral ptosis of variable severity
Absent upper lid crease
In down gaze the ptotic lid is higher than the normal
because of poor relaxation of levator.
25. OTHER ASSOCIATIONS
Superior rectus weakness may be present.
Compensatory chin elevation, especially in
bilateral cases.
Refractive errors are common.
TREATMENT
a. Levator resection.
b. Should be done during pre school years.
26. 2. MARCUS GUN JAW_WINKING SYNDROME
About 5% of all cases of Congenital Ptosis manifest
Marcus Gun Jaw-winking phenomenon
Postulated that a branch of the mandibular division
of 5th cranial nerve is misdirected to the levator
muscle.
SIGNS
Retraction of the Ptotic lid in conjunction with
stimulation of the ipsilateral pterygoid muscle by
chewing, sucking, opening mouth or jaw movement.
Jaw winking does not improve with age.
27. SURGERY
Possible procedures which can improve
cosmesis.
Unilateral levator resection.
Unilateral levator disinsertion.
Bilateral levator disinsertion
28. 3rd NERVE MISDIRECTION SYNDROME
Misdirection syndrome may be congenital or
acquired,or follow acquired 3rd nerve palsies.
SIGNS
Bizare movements of the upper lid which
accompany various eye movements.
TREATMENT
Levator disinsertion and brow suspension
30. INVOLUTIONAL PTOSIS
Age- related condition caused by dehiscence, disinsertion or
stretching of the levator aponeurosis.
This restricts transmission of force from a normal levator
muscle to the upper lid.
SIGNS
Variable bilateral ptosis.
High upper lid crease.
In severe cases upper lid crease may be absent.
TREATMENT
Options include.
Levator resection ,advancement with re insertion.
32. MECHANICAL PTOSIS
Result of impaired mobility of the upper lid.
May be caused by large tumours, heavy scar
tissue, severe oedema and anterior orbital
lesions.
34. PTOSIS SURGERY OPTIONS
1 CONJUNCTIVA-MULLER RESECTION
Indications
Mild Ptosis with Levator Function of at least 10mm
Maximum lift of the lid is 2-3mm.
Useful in mild Congenital Ptosis and Horners Syndrome.
35. 2. LEVATOR RESECTION
Indications
Any cause provided Levator
function is at least 5mm.
Technique
Involves shortening of
Levator Complex through
either skin or posterior
conjuctiva approach.
37. SURGRY OPTIONS Cont”d
3. BROW SUSPENSION
Indications
Severe Ptosis (over 4mm) with poor levator function.
Marcus Gun jaw-winking syndrome
Ptosis associated with aberrant regeneration of 3rd nerve.
Unsatisfactory result from previous levator resection
SURGERY
Involves suspension of the tarsus from the frontalis muscle
with a sling of fascia lata or non absorbable material such as
prolene or silicone.