you will get knowledge about the ptosis, its different types, its examination, its measurement, its treatment in detail.
different eyelid muscles such as LPS, Orbicularis oculi and frontalis are also explained.
3. PTOSIS
Ptosis is an abnormally low
position of the upper lid.
Grading and severity
Normally upper eyelid cover 1/6th of cornea
Mild < or = 2mm
Moderate = 3mm
Severe > 4mm
4. FUNCTIONAL ANATOMY
Levator Palpebral Superioris (LPS):
Is the primary muscle responsible for lid elevation.
It arises from the back of the orbit and extends forwards
over the cone of eye muscles.
It inserts into the eyelid and the tarsal plate, a fibrous
semicircular structure which gives the upper eyelid its
shape.
The LPS is supplied by the superior division of the
oculomotor nerve.
5. Muller’s Muscle:
The way that the LPS attaches to the tarsal plate is
modified by the underlying Müller's muscle.
This involuntary muscle, comprising sympathetically
innervated smooth muscle
Has the capacity to 'tighten' the attachment and so raise
the lid a few millimetres.
Frontalis and Orbicularis Oculi muscles:
Both muscles supplied by the facial nerve.
Frontalis contraction helps to elevate the lid by acting
indirectly on the surrounding soft tissues, while orbicularis
oculi contraction depresses the eyelid.
6. CLASSIFICATION
It may be
Acquired
Congenital
Acquired
1) Neurogenic
2) Myogenic
3) Aponeurotic
4) Mechanical
5) Neurotoxic
7. 1). NEUROGENIC
It caused by an innervational defect such as 3rd nerve
paresis and Horner's Syndrome.
3rd nerve misdirection syndrome
• Rare, unilateral
• Aberrant regeneration following acquired 3rd nerve palsy
• Bizarre movements of upper lid accompany eye
movements
• Pupil is occasionally involved
• Right ptosis primary position
• Worse on right gaze
• Normal on left gaze
8. HORNER SYNDROME:
It is a relatively rare disorder characterized by:
A constricted pupil (miosis)
Drooping of the upper eyelid (ptosis)
Absence of sweating of the face (anhidrosis)
Sinking of the eyeball into the bony cavity that protects
the eye (enophthalmos)
9. 2). MAYOGENIC:
Caused by the myopathy of the levator muscle itself or
by the impairment of the transmission of impulses at the
neuro muscular junction
Acquired myogenic occurs in myasthenia gravis
myotonic dystrophy and progressive external
ophthalmoplegia.
10. 3). APONEURATIC
Caused by a defect in
the levator aponeurosis
Involutional ptosis
Aponeuratic ptosis also called senile or involutional ptosis, is the
most common type of acquired ptosis. It is caused by a disinsertion
or dehiscence of the levator aponeurosis from the tarsus.
Clinical exam reveals a high lid crease, generally good levator
function and typically worsening of the ptosis on downgaze.
Such patients tend to do well with surgical correction which
involves advancement and reattachment of the levator
aponeurosis to the anterior tarsal surface.
11. 4). MECHANICAL:
With mechanical ptosis, the eyelid is weighed down by
excessive skin or a mass.
Traumatic ptosis is caused by an injury to the eyelid.
Either due to an accident or other eye trauma.
This injury compromises or weakens the levator muscle
12. CONGENITAL
1) Simple congenital ptosis
2) Congenital ptosis
3) Congenital synkinetic ptosis
4) Blepharophimosis Syndrome
1). Simple congenital ptosis
Not associated with any anomaly
13. 2). Congenital ptosis
It results from a failure of neuronal migration or development with
muscular sequalae.
Superior Rectus weakness
Compensatory Chin elevation
Absent upper lid crease
In downward gaze the ptotic lid is higher then the normal because
of poor relaxation of the levator function
3). Congenital Synkinetic ptosis
Marcus Gun Jaw winking Ptosis
14. MARCUS GUN JAW WINKING PTOSIS
About 5% of the congenital cases are associated with the Marcus
gun jaw winking phenomenon.
Retraction of the ptotic lid in conjunction with stimulation of the
ipsilateral
Pterygoid muscle by chewing, sucking, opening the mouth
Less common stimuli to winking include jaw protrusion, smiling,
swallowing and clenching of teeth
Jaw winking does not improve with age
Exact aetiology is unclear
15. PSEUDOPTOSIS
False impression of the ptosis which may be caused by:
LACK OF SUPPORT
Lack of support of the lids by the globe ma be due to the orbital
volume deficient associated with enophthalmos.
CONTRALATERAL LID RETRACTION
Which is detected by comparing the levels of upper eyelids the
margin of the upper lid mat cover the superior 2mm of cornea
IPSILATERAL HYPOTROPIA
Upper lid follows the globe downward
BROW PTOSIS
• Due to excessive skin on the brow
16.
17. SIGN AND SYMPTOMS OF PTOSIS
Dropping eyelid
Raising of the eyebrows to lift the eyelids for better
vision
Watery eye
Tilting the head
Aching in and around the eyes
Looking tired
Double vision
Difficulty closing the eyes or blinking
18. EVALUATION OF PTOSIS:
History:
Age of onset
Duration
One/both eye
Diurnal variability
Associated history:
o Diplopia
o Dysphagia
o Muscle weakness
Vision
19. Associated with:
Jaw movements
Abnormal ocular movements
Abnormal head posture
History of:
Trauma or previous surgery
Poisoning
Use of steroid drops
Any reaction with anesthesia
Bleeding tendency
Previous photographs may prove to be of great help.
Is there a family history of ptosis or of other muscle
weakness?
20. OCULAR EXAMINATION
Normal position of eyelids:
The normal upper eyelid in primary position
Crosses the iris b/w the limbus (junction of the iris and sclera)
and the pupil
Usually 1 mm to 2 mm below the limbus
The lower lid touches or crosses slightly above the limbus.
Normally there is no sclera showing above the iris.
Palpebral fissures:
It is normally 9 mm to 12 mm from upper to lower lid margin
Visual Acuity:
Best-corrected visual acuity should be assessed to record any
amblyopia if present, especially in cases of congenital ptosis.
21. PUPILLARY EXAMINATION
TO diagnosis Horner’s syndrome
Involvement in a case of third nerve palsy
TOTAL UNILATERAL PTOSIS
Complete third nerve palsy.
MILD TO MODERATE PTOSIS
Horner's syndrome
partial third nerve palsy.
MILD TO MODERATE BILATERAL PTOSIS
Neuromuscular disorders such as MG
Muscular dystrophy
Ocular myopathy
22. MEASUREMENTS
1) Margin reflex distance
2) Vertical fissure height
3) LPS action
4) Lid crease level
5) Lid level on down gaze
23. 1). MARGIN REFLEX DISTANCE:
Margin-to-reflex distance 1 (MRD1)
• When light is thrown on the cornea, a reflection
occurs.
• The distance from the central pupillary light reflex to
the upper eyelid margin with the eye in primary gaze.
• If the margin is above the light reflex the MRD 1 is a
+ve value.
• If the lid margin is below the corneal reflex in cases of
very severe ptosis the MRD 1 would be a –ve value.
24.
25. 2). VERTICAL FISSURE HEIGHT
The distance between the upper and lower eyelid in vertical
alignment with the center of the pupil in primary gaze, with the
patient’s brow relaxed.
Normal – 9-10mm in primary gaze
Should be seen in up gaze, down gaze and primary gaze
Amount of ptosis = difference in palpebral apertures in unilateral
ptosis or Difference from normal in bilateral ptosis
26. 3). LEVATOR FUNCTION ASSESSMENT
It is determined by the 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 the
examiner.
Levator function is graded as follows:
Normal 15 mm
Good 8 mm or more
Fair 5-7 mm
Poor 4 mm or less
32. LEVATOR RESECTION
Indicated for any ptosis provided levator function is at least 5mm.
Contraindicated in patients having severe ptosis with poor
levator function.
33. FRONTALIS BROW SUSPENSION
Used in severe ptosis with poor levator function (4 mm or less).
The tarsal plate is suspended from the frontalis muscle with a
sling consisting of autologous fascia lata or non absorbable
material such as prolene or silicon.
Marcus Gunn jaw-winking syndrome