drooping of eye lids

1. EVALUATION OF PTOSIS
BY DR NIKITA JAISWAL
MS RESIDENT
IMS AND SUM HOSPITAL

2. BLEPHAROPTOSIS
OR
PTOSIS:ABNORMALLY LOW POSITION OF UL IN PRIMARY GAZE
IN NORMAL GAZE IT COVERS 1/6TH OF THE CORNEA, I.E 2 MM .
IN PTOSIS IT COVERS MORE THAN THAT.
PTOSIS {DERIVED FROM: GREEK LANG.}
MEANS : TO FALL
Mr bell clicked it in 1952

3. BEFORE ANY JUDGEMENT WE NEED TO DIFFERENTIATE
BETWEEN :-
PSEUDOPTOSIS[SIMULATED PTOSIS}
TRUEPTOSIS

4. PSEUDOPTOSIS :IT IS TO BE RULED OUT ON
INSPECTION
IPSILATERAL CONDN: MICROPHTHALMOS
PTHISIS BULBI
ENOPHTHALMOS
PROSTHESIS
DERMATOCHALASIS
CONTRALATERAL CONDN: EYELID RETRACTION
HIGH MYOPIA
PROPTOSIS

5. ptosis
acquired
NEUROGENIC
MYOGENIC
APONEUROTIC
MECHANICAL
congenital

6. PSEUDOPTOSIS
Pthisis bulbi Enophthalmos

8. PRESENTING COMPLAINTS OF THE PATIENT Drooping of
the eyelids
since a
definite
period
Associated
decreased vision
unaware of the
eyelids

9. GRADING: MILD PTOSIS: 2MM
MODERATE PTOSIS: 3 MM
SEVERE PTOSIS : 4 MM

10. EVALUATION

11. CLINICAL EVALUATION FOLLOWS:
HISTORY:THE RULE OF “ODP” SHOULD BE KEPT IN MIND
THROUGH HISTORY SHOULD BE EXTRACTED FROM THE PATIENT THE PREVIOUS
PHOTOGRAPH CAN HELP DISTINGUISH THE AGE OF PTOSIS AS
THE PATIENT MAY BE GIVING IRRELEVANT HISTORY.

12. MARGIN-REFLEX DISTANCE: DISTANCE BETWEEN THE UPPER
LID MARGIN AND THE CORNEAL REFLECTION OF A PEN
TORCH HELD BY US AT WHICH THE PATIENT IS DIRECTLY
LOOKING.
NORMAL IS 4-4.5 MM

13. PALPEBERAL FISSURE HEIGHT: DIST BETWEEN THE UL AND LL MARGINS
THE UL MARGIN 2MM BELOW THE UPPER LIMBUS AND THE LL MARGIN 1MM ABOVE THE LOWER
LIMBUS
IN MALES: 7-10 MM
IN FEMALES: 8-12 MM
CAN BE CLASSIFIED AS MILD
MODERATE
SEVERE

14. LEVATOR FUNCTION:PLACE A THUMB FIRMLY OVER PATIENTS BROW TO NEGATE
THE ACTION OF FRONTALIS MUSCLE WITH THE EYES IN DOWNGAZE THEN THE PATIENT IS
ASKED TO LOOK UP AS FAR AS POSSIBLE THEN THE EXCURSION IS MEASURED BY A RULER.

15. UPPER LID CREASE: IT IS VERTICAL DISTANCE BETWEEN THE LID MARGIN AND THE LID
CREASE IN DOWNGAZE………
FEMALES:10 MM
MALES: 8 MM

16. ASSOCIATED SIGNS:
FATIGABILITY: ASK THE PAT. TO LOOK UP WITHOUT BLINKING FOR 30 SECONDS IF
THE PATIENTS FAILS TO MAINTAIN THE UPWARD GAZE IS SUGGESTIVE OF M.G
COGAN TWITCH SIGN: OVERSHOOT OF THE UL ON SACCADE FROM DOWNGAZE TO THE
PRIMARY POSITION.

17. JAW WINKING PHENOMENON:CAN BE SEEN IF THE PATIENT IS PTOTIC
AND WE ASK THE PATIENT TO CHEW OR OPEN HIS/HER MOUTH.

18. BELLS PHENOMENON: IT IS TESTED BY MANUALLY HOLDING THE LIDS
OPEN,ASKING THE PATIENT TO TRY TO SHUT HIS EYES AND OBSERVING THE UPWARD AND
OUTWARD ROTATION OF THE GLOBE

19. OTHER BATTERY OF TESTS

20. THIS TEST IS AN EASY OPD BASE PROCEDURE
ASK THE PATIENT TO SIT COMFORTABLY
ASK HIM/HER TO CLOSE THEIR EYES
HOLD AN ICE PACK OVER THE CLOSED EYES
WAIT FOR 5 MINUTES
OBSERVE AFTER 5 MINUTES
NOTE ANY IMPROVEMENTS

21. EDROPHONIUM(TENSILON)TEST:
EDROPHONIUM CHLORIDE INHIBITS ACETYLCHOLINESTERASE
IT RESULTS IN THE PROLONGED PRESENCE OF ACT A THE NMJ
THIS RESULTS IN ENHANCED MUSCLE STRENGTH
POSITIVE: ELEVATION OF EYELIDS IN 2-5MINS POST ADMINISTRATION OF TENSILON
NEGATIVE: NO IMPROVEMENT EVEN 3 MINUTES
DRAWBACK: THIS HAS A RELATIVELY LOW SENSITIVITY APPROX. 60% FOR MG
S/E: DUE TO OVERACTIVATION OF THE PARASYMPATHETIC SYSTEM & CAUSE UNWANTED S/E
FAINTING,DIZZINESS,INVOLUNTARY DEFECATION, SEVERE BRADYCARDIA,APNEA, AND THE MOST DREADED ONE
CARDIAC ARREST.
SAVIOR: ATROPINE AT HAND

22. OPTIONS ARE EVERYWHERE
EYELIDS CRUTCHES A PROTOTYPE EXTERNAL
MAGNETS