3. Ptosis (from Greek Ptosis -to "fall") is drooping or falling
of the upper eyelid below its normal position. "lazy eye"
4. Levator Palpebrae Superioris
Primary muscle for lid elevation.
Supplied by the superior division of the oculomotor nerve.
Arises from the back of the orbit and extends forwards over the
cone of eye muscles.
Inserts into the eyelid and the tarsal plate, a fibrous semicircular
structure which gives the upper eyelid its shape.
10. Clincal Features
Dominent 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
11. 4. Congenital synkinetic ptosis
(Marcus Gunn jaw winking ptosis).
In this condition there occurs retraction of the
ptotic lid with jaw movements i.e., with
stimulation of ipsilateral pterygoid muscle.
12. Usually unilateral
Types :
1. Neurogenic
Third nerve paralysis
Due to reduced sympathetic innervation (Horner
syndrome – ptosis, anhydrosis and miosis)
16. 3. Mysthenia Gravis
Signs – bilateral ptosis, increases by prolonged
fixation or attempt to look up , external
ophthalmoplegia – partial or complete
Conformation by edrophonium injection test
17. 1. Post Operative ptosis due to disinsertion of
Levator Palpebrae Superioris aponeurosis
from ant surface of tarsal plate.
2. Posttraumatic Dehiscence or Disinsertion
3. Involutional (snile) ptosis due to weakness.
Clincal sign
High fold with good Levator palpebrae superioris
function.
18. High upper lid crease Good levator function
Deep sulcusAbsent upper lid crease
Mild
Severe
19. Ptosis is caused by the gravitational effect
of a mass or by scarring
Tumour or inflammation weight down the lid
22. False impression of ptosis may be caused
by the following
1. Lack of support of the lids by the globe
may be due to an orbital volume deficit
associated with an artificial eye
23.
24.
25.
26.
27. 1. Diagnosis is based on
history
examination,
eye measurements,
clinical and laboratory tests and
imaging studies
2. Treatment
28. 1. Age of onset
2. Duration
3. One/both eye
4. Associated history
5. Diplopia
6. Dysphagia
7. Muscle weakness
8. Vision
9. Jaw movements
10.Abnormal ocular
movements
11.Abnormal head
posture
12.Previous history
13.Trauma
14.Poisoning
15.Bleeding tendency
16.Previous photographs
17.Family history
29. NORMAL POSITION OF EYELID
Usually 1-2mm below the limbus
Vertical Palpebral fissures are normally 9-12mm.
Check for
1. Unilateral or bilateral , Complete or incomplete
2. Ocular motility
3. Visual acuity
4. Pupillary examination
5. Chin elevation
31. Normal – 9-
10mm in
primary gaze
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
32.
33.
34. MRD 2
The distance from the central pupillary light reflex to the lower
eyelid margin with the eye in primary gaze.
The MRD1 plus the MRD2 should equal the palpebral fissure
measurement
35. Lid excursion is a measure of the levator function. The
frontalis action is blocked by keeping the thumb tightly
over the upper brow and asking the patient to look up
from down gaze and measuring the amount of upper
lid excursion at the center of the lid.
36.
37. Is the distance from the
crease to lid margin
Normal – 8 to 10mm in
primary gaze
An absent lid crease is often
accompanied by poor levator
function.
If a lid crease is present but
is higher than normal and if
a deeper upper lid sulcus is
found on that side, note
these as signs of a levator
aponeurosis disinsertion.
38. Patients with Minimal
ptosis (2 mm or less)
2.5 or 10% phenylephrine
is instilled in the affected
eye or eyes
The patient is reexamined 5
minutes later.
The MRD1 is rechecked in
the affected and unaffected
eyes .
A rise in the MRDl of 1.5
mm or greater is
considered a positive
test. This indicates that
Müller's muscle is viable
39. Non Surgical
Surgical
Herrings Law
Muscles that elevate the eyelids get the same
innervation
The lid with minimal ptosis droops more following
the correction of greater ptotic side
Important for prediction of post op results
43. Surgical management depends upon the type of ptosis
and levator function
Indications
Complete ptosis
Chin up positioning
Severe ptosis causing amblyopia
Contraindications
Poor orbicularis muscle function
Loss of blink reflex
Corneal sensitivity
Keratitis sicca