PTOSIS
GRANDSON KELVIN JERE
LECTURER – DEPT. OF OPHTHALMOLOGY AND
OPTOMETRY

PTOSIS
Definition
Abnormal low position of upper lid.
May be Congenital or Acquired

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

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.

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.

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

Pseudoptosis Rt Phthisis bulbi

PSEUDOPTOSIS –Cont”d
d) Brow Ptosis
 Due to excessive skin on the brow or 7th nerve palsy.
e) Dermatochalasis
 Excessive skin on upper lid.

Pseudoptosis Contralateral lid retraction

Pseudoptosis - Ipsilateral Hypotropia

Pseudoptosis bilateral brow ptosis

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

Margin reflex distance

Palpebral fissure height

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

Levator function

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

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.

Jaw-winking 1

Jaw winking 2

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.

Congenital Mild Right Ptosis

Congenital severe left ptosis

Congenital severe bilateral ptosis

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.

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.

SURGERY
Possible procedures which can improve
cosmesis.
 Unilateral levator resection.
 Unilateral levator disinsertion.
 Bilateral levator disinsertion

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

3rd Nerve misdirection syndrome

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.

Involutional ptosis

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.

Mechanical ptosis neurofibroma

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.

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.

Conjuctiva-muller resection

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.

Brow suspension