A little view about ptosis approach

1. Ptosis
DrAhmadZulfahmiShaari
OphthalDept

2. OUTLINE
Definition
Classification
-congenital
-acquired
Evaluation of ptosis

3. DEFINITION
• Ptosis (from Greek Ptosis -to "fall") is a
drooping or falling of the upper or lower
eyelid.

4. CLASSIFICATION OFPTOSIS
A. Congenital
B. Acquired
1. Neurogenic
2. Myogenic
3. Aponeurotic
4. Mechanical
5. Neurotoxic
C. PseudoPtosis

5. Congenitalptosis
• It is associated with congenital weakness(maldevelopment)
of the levator palpebrae superioris(LPS).
1. Simple congenital ptosis.
2. Congenital ptosis with associated weakness ofsuperior
rectus muscle.
3. Blepharophimosis syndrome.
4. Congenital synkineticptosis (Marcus Gunn jaw winkingptosis).

6. ACQUIRED PTOSIS
1.Neurogenic : 3rd nerve palsy/ Horner syndrome
2.Myogenic : MG/ myopathies
3. Aponeurotic: Senile/postoperation
4. Mechanical : Tumours/chalazia
5. Neurotoxic : Envenomation

7. EVALUATION OFPTOSIS

8. HISTORY
• Ptosis
– Ageof onset
– Duration
– One/both eye
– Diurnal variability/ fluctuating
• Associated history :
– Diplopia
– Unequal pupil/ iris color
– Cancer? Constitutional Sx

9. • Association with
– Jawmovements
– Abnormal ocular movements
– Abnormal head posture
• History of
– Traumaor previous surgery
– Useof steroid drops
– Any reaction with anesthesia/ bleeding disorder
– Drug/allergic reaction
• Previous photographs may prove to be ofgreat
help.
• Is there afamily history of ptosis or of other muscle
weakness?

10. Ocular Examination:
NORMAL POSITION OFEYELIDS
• Thenormal upper eyelid in primaryposition
– crossesthe iris between the limbus (junction ofthe iris
and sclera) and the pupil,
– usually 1 mm to 2 mm below thelimbus;
– the lower lid touches or crossesslightly above
the limbus.
– Normally there is no sclera showing above the iris.
• Thepalpebral fissures:
– are normally 9 mm to 12mm from upper to lower lid
margin.

11. Look for…
• U/L orB/L
• Complete /incomplete (severity) : shine
torchlight to look at visual axis
• Totalunilateralptosis
– complete third nervepalsy.
• Mild to moderate unilateralptosis
– Horner's syndrome,
– partial third nervepalsy.
• Mild to moderate bilateralptosis
– neuromuscular disorders (eg MG),
– muscular dystrophy,
– Ocular myopathy.

12. • Pupillary Examination: anisocoria?
– Present: 3rdCN palsy/Horner’ssyndrome
– Absent: MG/ congenital ptosis/ senile ptosis
• Eye positions : squints?
• Head Posture:
– chin elevation asthe ptosis is minimum in downgazein a
patient with congenital ptosis.
– In severptosis there will be superior altitudinal defect
which is corrected by elevating theeyelids
• Lid crease, lid sulcus, lid mass.

13. EOM
1) Upgaze
– ptosis overcome by frontalis (Horner Syndrome)
- Limitation (3rd CN palsy)
2) Downgaze:
- lid lag present in congenital ptosis,
- more severe ptosis in aponeurotic,
- aberrant 3 CN regeneration (lid elevation upon depression)
3) Sidegaze : 3rd CN palsy, aberrant 3 CN regeneration (lid elevation upon
adduction)
MG test: fatiguebility in upgaze, cogan’s lid twitch, eyelash sign, eyepeek sign
Marcus Gunn Jaw Winking sign

14. A) Cocaine 4-10%
- prevents the reuptake of norepinephrine at the post-synaptic third-order
neuron thereby allowing dilation of the normal pupil.
- Confirmation test.
- Affected pupil not dilated.
B) Hydroxyamphetamine 1% (Paredrine)
- promote release of norepinephrine. Requires an intact third-order
sympathetic neuron to stimulate norepinephrine release causing dilatation.
- Postganglion lesion pupil fail to dilate.
*Therefore, an asymmetric dilation suggests a third-order or postganglionic
lesion whereas equal pupillary dilation indicates a central or preganglionic
lesion.
C) Phenylephrine 1%
- Denervation supersensitivity
- Postganglionic lesion pupil dilates more widely
D) Apraclonidine 0.5%
- causes constriction of the normal pupil due to its strong α-2 adrenergic
activity, it causes reversal of anisocoria in both central/ pre &
postganglionic.
Horner Syndrome Test

15. Measurements
1. Margin reflex distance (MRD)
2. Vertical fissure height
3. LPS action
4. Lid crease level
5. Lid level on down gaze
6. Bells phenomenon

16. 1. MARGIN REFLEX DISTANCE
• Margin-to-reflex distance 1 (MRD1) :
– When light is thrown on the cornea areflectionoccurrs
.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 lightreflex the MRD1 is a
+vevalue.
• If the lid margin is below the corneal reflex in cases
of very severe ptosis the MRD1 would be a–ve
value.

18. Marginal reflexdistance
• Distance between upper lid
margin and cornal light reflex
(MRD)
• Mild ptosis (2 mm ofdroop)
• Moderate ptosis (3mm)
• Severeptosis (4 mm or more)

19. 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

21. Grading of severity of ptosis
< or = 2mm : mild ptosis
= 3 mm : moderate ptosis
= or > 4 mm : severe ptosis

22. 3.Levatorfunctionassesment
• It is determined by the lidexcursion causedby LPS
muscle (Burke’smethod).
– Patient is askedto 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 theexaminer.
– Levator function is graded asfollows:
• Normal 15 mm
• Good 8 mm or more
• Fair 5-7 mm
• Poor 4 mm or less

23. • Reflects levator function
• Normal (15 mm ormore)
• Good(8 mm ormore)
• Fair (5-7mm)
Upper lid excursion- burke’s,method
• Poor (4 mm orless)

24. Upper lidcrease Pretarsal show
crease fold
• Distance between lid margin andlid
creasein down-gaze
• Normals - females 10 mm; males 8m
• Absencein congenital ptosisindicates
poor levator function
• High creasesuggestsan aponeurotic
defect
• Distance between lash line and
skin fold in primary position of
gaze
m

26. Icetest

27. TQ