PTOSIS

1. PTOSIS

2. FUNCTIONAL ANATOMY
• Levator palpebrae superioris(LPS)
-Primary muscle responsible for lid elevation.
-Arises from the apex of the orbit
-inserted by 3 parts on skin of eyelid and anterior surface of tarsal plate
and conjunctiva of superior fornix
-supplied by the superior division of occulomotor nerve.

3. FUNCTIONAL ANATOMY
• Mullers muscles
-LPS attachment to the tarsal plate is modified by underlying muller’s
muscle.
-This is an involuntary muscle comprising sympathetically innervated
smooth muscle.
-It has the capacity to tighten the attachment and so raise the lid a few
millimetres

4. FUNCTIONAL ANATOMY
• Frontalis and orbicularis oculi
-Both are supplied by facial nerve.
-Frontalis contraction helps to elevate the lid by acting indirectly on surrounding soft
tissue
-Orbicularis muscle forms an oval sheet across the eyelids.It comprises of 3 portions
Orbital part encircles the orbital margin
Preseptal part lies anterior to septum orbitale and lossely attached to it
Pretarsal part is adhered firmly to tarsus

6. DEFINITION
• Ptosis is defined as the upper eyelid resting
in a droopy,abnormally low position while
the eye is in primary gaze.
• Normally upper eyelid covers 1/6th of the
cornea i.e about 2mm
• In ptosis it covers more than 2mm.

7. CLASSIFICATION OF PTOSIS
A. Congenital
B. Acquired
1. Neurogenic
2. Myogenic
3. Aponeurotic
4. Mechanical
5. Neurotoxic

8. Congenital ptosis
• It is associated with congenital weakness(maldevelopment) of leavator palpebrae superioris(LPS).
1. Simple congenital ptosis-not associated with any other anomaly
2. Congenital ptosis with associated weakness of superior rectus muscle
3. Blepharophimosis syndrome which compromise congenital
ptosis,blepharophimosis,telecanthus and epicanthus inversus.
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

9. Congenital ptosis

10. Blepharophimosis syndrome
• Rare congenital disorder
• Dominant inheritance
• Moderate to severe symmetrical ptosis
• Short horizontal palpebral aperture
• Telecanthus(lateral displacement of medial canthus)
• Epicanthus inversus(lower lid fold larger than upper)
• Lateral inferior ectropion
• Poorly developed nasal bridge and hypoplasia of superior
orbital rims

11. Congenital synkinetic ptosis
• This condition is characterized as a synkinesis:
When two or more muscles that are independently innervated have either
simultaneous or coordinated movements.
In Marcus Gunn Phenomenon
The stimulation of trigeminal nerve by contraction of pterygoid muscles of jaw results
in the excitation of the branch of the oculomotor nerve that innervates the LPS
ipsilaterally,so the patient will have rhythm upward jerking of their upper eyelid
It occurs due to trigemino-oculomotor synkinesis.

12. Grading of Marcus Gunn Phenomenon
• Mild-maximum elevation of ptotic
eyelid to non-ptotic position
• Moderate-maximum elevation goes
upto superior limbus
• Severe-maximum elevation beyond the
superior limbus with scleral show

13. ACQUIRED PTOSIS
1. Neurogenic
-Third nerve palsy
-Third nerve misdirection
-Horners syndrome
2. Myogenic
3. Aponeurotic
4. Mechanical
5. Neurotoxic

14. NEUROGENIC PTOSIS
• It is caused by innervational defects such as third nerve palsy
• 3rd nerve misdirection
• Horner’s syndrome
• Ophthalmoplegic migraine
• Cerebral ptosis
• Multiple sclerosis

15. LEFTTHIRD NERVE PALSY

16. BELL’S PHENOMENON
• Upward rotation of globe on lid closure
• GRADING
Good= >2/3 of cornea disappears
Fair=1/3-2/3rd of cornea disappears
Poor=<1/3rd of cornea disappears
• VARIANT
Inverse-upward and inward
Reverse-downward and outward
Preverse-different directions

18. Horner’s syndrome
• Occurs due to oculo-sympathetic paresis
• Characterised by classic triad of:
-Mild ptosis(due to paralysis of muller’s
muscle)
-Miosis(due to paralysis of dilator pupillae)
-Reduced ipsilateral sweating(anhydrosis)
• Other features include mild enophthalmos,loss of
cilio-spinal reflex,heterochromia.

19. IMPORTANT CAUSES OF HORNER’S
SYNDROME

20. MYOGENIC PTOSIS
• It is due to acquired disorders of the LPS muscle or of the myoneural
junction
1. Myasthenia gravis
2. Myotonic dystrophy
3. Ocular myopathies
4. Oculo-pharyngeal muscle dystrophy
5. Following trauma to the LPS muscle

21. Myasthenia gravis
• Ptosis in MG is frequently asymmetric and may be unilateral,though it will
tend to shift from side to side.
• It characteristically fluctuates from moment to moment and is worsened by
prolonged upgaze (fatiguable ptosis)
• Cogan’s lid twitch sign
-characterstic of myasthenia,consists of a brief overshoot twitch of lid
retraction following sudden return of eyes to the primary position after a period
of downgaze.

22. Myasthenia gravis
• Curtain sign,seesaw ptosis:
-When the ptosis is asymmetric,the driving discharges attempting to
keep the more ptotic eyelid open are also transmitted,per Hering’s law,to the
less ptotic eyelid
-Manually raising the more ptotic lid causes relaxation and the eye with
less ptosis,sometimes even no ptosis,may suddenly crash.

23. Cogan’s lid twitch sign Curtain sign

24. Myasthenia gravis
• Investigations
-Edrophonium(camiston)test
-Ice pack test
-Electromyography to confirm fatigue
-Antibodies to acetylcholine receptors
-CT or MRI for presence of thymoma
• Treatment options
-Medical-anticholinesterases,steroids and azathioprine
-Thymectomy

25. Edrophonium(Tensilon) Test
• Edrophonium chloride inhibits acetylcholinesterase
• Thereby prolonging the presence of acetylcholine at the neuromuscular junction which results in
enhanced muscle strength
• In ptosis,a positive test is the elevation of eyelids in 2-5 mins post administration of Tensilon
• A negative response in no improvement within 3 minutes
• Sensitivity-60%
• False positive results occur in patients with
-Lambert-Eaton Myasthenia Syndrome(LEMS)
-Amyotropic Lateral Sclerosis(ALS)
-localized intracranial mass lesions

27. ICE PACK TEST
• Ice pack is applied to the affected
upper eyelid fo 2-5 minutes.
• Positive test is improvement of ptosis
by 2mm or more.
• This transient improvement in ptosis
is due to the cold decreasing
breakdown of acetyl choline at N-M
junction.

28. MYOTONIC DYSTROPHY

30. APONEUROTIC PTOSIS
• Develops due to defects of the levator aponeurosis in the presence of a
normal functioning muscle.
• It includes
-involutional(senile) ptosis
-postoperative ptosis:due to aponeurotic weakness associated with
blepharochalasis
-Post traumatic dehiscence or disinsertion of the aponeurosis.

31. Senile ptosis
• Senile or involutional ptosis is very common.
Asymmetric lids and redundant lid tissue in the elderly
• The levator aponeurosis attaches the levator muscle to the tarsal plate,which forms
the eyelid
• Aging may cause levator dehiscence disinsertion(LDD)-with stretching thinning or
detachment of aponeurosis.
• Normally,with the eyelids gently closed, the upper lid margin lies 5mm to 7mm
below the upper lid fold
• An increase in this distance suggests LDD.

33. Mechanical ptosis
• Due to excessive weight on the
upper lid
-lid tumors
-multiple chalazia
-lid oedema
• Cicatrial Ptosis
-ocular pemphigoid
-trachoma

34. Neurotoxic ptosis
• Evenomation by elapids such as cobras or kraits
-Bilateral ptosis is usually accompanied by diplopia,dysphagia and/or
progressive muscular paralysis
-Regardless,neurotoxic ptosis is a precursor to respiratory failure and
eventual suffocation caused by complete paralysis of the thoracic
diaphragm
-It is therefore a medical emergency and immediate treatment is
required

35. PSEUDOPTOSIS
• It is the appearance of ptosis in the absence of levator abnormality
• Exclude pseudoptosis (simulated ptosis) on inspection
• Its common causes are:
-Microphthalmos -Double
elevator palsy
-Anophthalmos -
Blepharospasm
-Enophthalmos -
Contralateral proptosis
-Phthisis bulbi

37. EVALUATION OF
PTOSIS

38. HISTORY
• Ptosis
-Age of onset
-Duration
-One/both eye
-Diurnal variability
• Associated history
-Diplopia
-Dysphagia
-Muscle weakness
• Vision
• Associated with
-Jaw movements
-Abnormal ocular movements
-Abnormal head posture
• History of
-Trauma or previous surgery
-Poisoning
-Use of steroid drops
-Any reaction with anaesthesia
-Bleeding tendency
• Family history
• Old photographs

39. EXAMINATION
• Head posture
• Periocular fullness
• Frontalis overaction
• Scar mark
• Lid skin laxity
• Telecanthus,epicanthus inversus
• Corneal sensation
• Lagophthalmos
• Schirmers test
• Any associated mass lesions

40. PTOSIS
• U/L or B/L
• Complete/incomplete
• Total unilateral ptosis-complete third nerve palsy
• Mild to moderate unilateral ptosis-Horner’s syndrome,partial third nerve palsy
• Mild to moderate bilateral ptosis-Neuromuscular disorders such as MG,Muscular
dystrophy,Ocular myopathy

41. OCULAR EXAMINATION
• Ocular motility
-importance in myogenic ptosis
-to rule out 3rd nerve palsy
• Visual acuity
-BCVA should be assessed to record any amblyopia if present
• Pupillary examination
-to diagnose Horner’s syndrome
-Involvement in case of 3rd nerve palsy
• Refraction-indicated in all children with ptosis to assess anisometropia due to astigmatism on
ptotic side.

42. MEASUREMENTS
1. Margin reflex distance
2. Vertical fissure height
3. LPS action
4. Margin crease distance
5. Margin limbal distance

43. 1.MARGIN REFLEX DISTANCE
• Margin to reflex distance 1(MRD1)
-When the 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.
• Normal:4-5mm
• If the margin is above the light reflex the MRD1 is a +ve value.
• If the lid margin is below corneal reflex in cases of very severe ptosis the MRD1
would be a –ve value.

46. 1.MARGIN REFLEX DISTANCE
• Margin reflex distance 2 (MRD 2)
The distance of corneal light reflex to the centre of lower eyelid margin
in primary gaze
Normal value is 5-5.5mm
• Margin reflex distance 3 (MRD 3)
the distance between corneal light reflex and centre of upper eyelid
margin in extreme upgaze.

47. 2.VERTICAL FISSURE HEIGHT
• 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 upgaze,downgaze and primary gaze
• Amount of ptosis= difference in palpebral apertures in unilateral ptosis or
difference from normal in bilateral ptosis.

49. 3.LEVATOR FUNCTION ASSESMENT
• 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)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 other hand by examiner.
-Levator function is graded as follows
▪ Normal-15mm
▪ Good- 8mm
▪ Fair- 7mm
▪ Poor- 4mm or less

51. 4.MARGIN CREASE DISTANCE(MCD)
• Measured with patient looking
down,distance from central eyelid margin
to the most prominent lid crease.
• Normal value
Men: 5-7mm
Women: 8-10mm
• Crease is absent in congenital ptosis and
higher in aponeurotic ptosis

52. 5.MARGIN LIMBAL DISTANCE(MLD)
• Also known as putterman’s method.
• It gives degree of loss of levator
action
• Measured as distance between
centre of upper lid margin to
6o’clock limbus in extreme upgaze
• Normally it is 9 mm

53. EXAMINATION
• Marcus gunn jaw winking phenomenon
• Bell’s phenomenon
• Fatigue test
• Cogan’s lid twitch sign
• Curtain sign
• Edrophonium test
• Ice pack test

54. EXAMINATION
• Phenylephrine test- Function of
muller’s muscle is tested by applying
drops of 10% phenylephrine
• A rise of MRD1 of 1.5mm or greater is
considered a positive test
• This indicates muller’s muscle is viable
so operation to resect muller’s muscle
and conjunctiva can relieve
blepharoptosis
• Function of orbicularis oculi muscle

55. NON SURGICAL MANAGEMENT
• Ptosis crutch glasses
• Apraclonidine(0.5%)/Oxymetazoline(0.1%):1-2 drops TDS
-Alpha agonist,causes contraction of muller’s muscle
and elevate lid by 1-2mm
• Onabotulinum toxin A-7 point injection technique of 20-40
units
-elevate lid by 0.5 to 1.3mm
-used in brow ptosis
• Pyridostigmine and corticosteroid in ocular MG

56. SURGICAL MANAGEMENT
• Mild ptosis
-Phenylephrine +ve: mullerectomy
-Phenylephrine –ve: Fasanella servat
-Blepharoplasty : Levator resection
• Moderate ptosis
-Levator resection/Levator advancement
• Severe ptosis
-Frontalis sling

57. TARSO-CONJUCTIVO MULLERECTOMY
(FASANELLA SERVAT PROCEDURE)
• Performed in cases of mild ptosis and good levator function
• Upper lid is everted and the upper tarsal border along with its
attached muller’s muscle and conjunctiva are resected.

59. LEVATOR RESECTION
• Most commonly performed surgery for moderate and severe ptosis
• Contraindicated in severe ptosis with poor levator function
Amount of LPS to be resected- Depending on the level of LPS function
Good : 16-17mm
Fair : 18-22mm
Poor function : 22-23mm
Severe ptosis(fair levator function) : 23-24mm

60. LEVATOR RESECTION
Techniques
1. Conjuctival approach(Blaskowic’s operation)
• Upper lid is doubly evereted over a desmarre’s lid retractor
• Incision is made through the conjunctiva near upper tarsal border
• LPS exposed and resected
2. Skin approach (Everbusch’s operation)
• More frequently employed technique
• Skin incision is made along the future lid crease
• It allows comparatively better exposure of LPS muscle

62. FRONTALIS SLING OPERATION
(BROW SUSPENSION)
• Performed in patients having severe ptosis with no levator function.
• Lid is anchored to the frontalis muscle via a sling.
• Fascia lata or some non-absorbable material(e.g.supramide suture,silicon rod) may
be used as a sling.
• In marcus gunn jaw winking ptosis,LPS excision is combined with frontalis sling
operation.
• In blepharophimosis syndrome,frontalis sling operation combined with telecanthus
correction and lateral cantholysis.
• For Horner’s syndrome:Fasanella servat operation.
• For neurogenic ptosis in 3rd nerve palsy: Frontalis sling operation.