Anatomy of the eyelid, causes of ptosis, clinical evaluation of ptosis and treatment.

1. Ptosis
BY: DIMA LOTFIE
13901022

2. What is ptosis?
From the Greek word "to fall"
 Drooping of the eyelid.
 can be bilateral or unilateral.

3. Anatomy of the eyelid : surface anatomy
 The upper eyelid extends superiorly to the eyebrow, which
separates it from the forehead.
 The lower lid extends below the inferior orbital rim to join the
cheek, forming folds where the loose connective tissue of the
eyelid is juxtaposed with the denser tissue of the cheek.

5. Anatomy of the eyelid: Layers
 The eyelid consists of 5 layers: (from outside to inside)
 1- skin and subcutaneous tissue
 2- orbicularis muscle
 3- levator APONEUROSIS
 4- tarsal plate
 5- conjunctiva

6. Anatomy of the eyelid: nerves
 Sensory innervation of the eyelids is achieved by trigeminal nerve, it
supplies somatosensory innervation to the eyelid via its ophthalmic and
maxillary divisions.
 Terminal branches of the ophthalmic division supply the upper eyelid as
the lacrimal, supraorbital, and supratrochlear nerves (lateral to medial).
 Motor: Eyelid muscle innervation is achieved by cranial nerve VII (the
facial nerve), cranial nerve III (the oculomotor nerve), and sympathetic
nerve fibers.

7. Anatomy of the eyelid: vessels
 The internal and external carotid arteries contribute to lid arterial
supply.
 The internal carotid arterial supply is from the terminal branches of
the ophthalmic artery medially (giving supraorbital, supratrochlear,
and dorsal nasal branches) and the lacrimal artery laterally.
 The external carotid artery contributes via branches of the facial
artery, the superficial temporal artery, and the infraorbital artery.

8. Anatomy of the eyelid: vessels cont…
 The facial artery provides the angular artery, which passes to the
medial canthal region, anastomosing with the dorsal nasal artery.
 The superficial temporal artery supplies eyelid anastomoses via
the transverse facial and zygomatic branches.
 The infraorbital artery exits the infraorbital foramen as a terminal
branch of the maxillary artery, anastomosing with vessels of the
lower eyelid.

9. Anatomy of the eyelid: lymphatics
 The eyelids have a rich lymphatic drainage. The drainage of most
of the upper lid and the lateral half of the lower lid is to the
preauricular lymph nodes.
 The medial portion of the upper lid and the medial half of the
lower lid drain into the submandibular nodes by way of vessels
that follow the angular and facial vessels.

10. What muscles are responsible for eyelid
retraction?
 1- levator palpebrae superioris (most important and most
commonly affected in ptosis)
 2- Müller's muscle
 3- frontalis muscle

12. Normal lid position
 Upper lid covers 16 of cornea (2
mm )
Not showing the sclera from above.
 Lower lid touches the limbus
You can see part of the sclera from
below.

13. Causes of ptosis
 Can be classified into congenital and acquired.
 1- Congenital:
 Levator Muscle dystrophy:
congenital weakness (maldevelopment) of the
levator palpebrae superioris (LPS).

14. Causes Cont…
2- Acquired (more important to know):
 Classified into:
1- Neurogenic*
2- Myogenic*
3- Aponeurotic*
4- Mechanical

15. Acquired ptosis:
1- Neurogenic: (problem with the nerve supply to LPS)
 Can be 3rd cranial nerve palsy
 Horner’s syndrome (remember The classic triad for Horner's
syndrome includes unilateral ptosis, ipsilateral miosis, and
anhidrosis)
 Multiple sclerosis

16. Acquired ptosis cont…
2- Myogenic:
 the problem is in the muscle itself or in the myoneural junction:
E.g: Myasthenia gravis (in 85% of patient with myasthenia gravis,
ptosis can be the initial symptom)
 Could be due to myotonic dystrophy
 Or trauma to the LPS muscle.

17. Acquired ptosis cont…
3- Aponeurotic (problem in the aponeurosis which connects the
muscle to the tarsal plate)
 Could be due to defect in the insertion or weakness of the
aponeurosis of the LPS muscle
 P.s : Aponeurotic ptosis is the most common type seen in adults
especially in old age.
 Clinically: the crease is often elevated (in mild ptosis) or absent (in
severe ptosis).

18. In the picture you see bilateral aponeurotic ptosis, Note the
elevated lid creases. There is compensatory frontalis over-
activation, causing elevation of the brows.

19. Acquired ptosis cont…
4- Mechanical: due to excessive weight on the upper lid
 Tumor
 Edema
 Dermatochalasis : excess of skin in the eyelid, also known as
"baggy eyes."
 Anterior orbital lesions

20. Clinical Evaluation Of Ptosis
 We need to know how severe ptosis is in order to manage it.
- In history taking, there are 5 main things you should focus on:
1- Onset
2- family history
3- history of trauma
4- Any eye surgery?
5- Variability in degree of ptosis

21. Clinical Evaluation cont…
2- In clinical examination, most important two things you should do:
 1- Measure the severity of ptosis
 2- Asses LPS muscle function
But first you should:
• Exclude pseudoptosis (simulated ptosis)
• Observe if ptosis is unilateral or bilateral
• Observe the function of orbicularis oculi muscle (its function is to close the eyelid)
• Check if eyelid crease is present or absent

22. Also..
• Check if Jaw-winking phenomenon is present or not
It is an associated winking motion of the affected eyelid on the movement
of the jaw, it's thought to be due to a congenital misdirection of the fifth
cranial nerve fibers into a branch of the third cranial nerve that supplies
levator muscle
• Associated weakness of any extraocular Muscle
• Bell’s phenomenon is present or absent: (an upward and outward
movement of the eye, when an attempt is made to close the eye).

23.  Now you can measure the amount (degree) of ptosis
By using marginal reflex distance (MRD); it's the distance between upper lid margin and light
reflex.
 (It measures how many millimeters of the cornea are covered by the upper lid)
 Normal MRD should be less than 2mm.
 2 mm of droop = mild ptosis
 3-4 mm of droop = moderate ptosis
 More than 4mm = severe ptosis
 - Why do we call it severe?
 Because at this stage, the lid starts covering the pupil ➡ affects the vision

24. LPS function assessment
 In left hand, you should hold the eyebrow of the patient (to prevent frontalis muscle
to play any role in elevating the lid), then ask the patient to look down, then to look
up ➡ measure the distance between the upper and lower gaze ..
 (Measuring the distance between down gaze and up gaze will tell you how many
millimeters LPS can actually lift your lid)
 Ideally, distance should be 12mm.
 The less the distance between upper and lower gaze = the poorer the LPS muscle
function
 Less than 4mm indicates VERY poor LPS function.
 4-8 mm = moderate function
 More than 8 mm is considered as a reasonably good function.

25. Additional notes
1- in congenital ptosis it's necessary to FIRST identity how severe it is
because it can lead to amblyopia.. ➡ management of ptosis in this case is
operation.
2- We need to asses the function of LPS muscle in order to decide the
management;
 we can do recession or resection if the function of LPS is still average.
 But if the muscle has a very poor function or lost its function completely,
resection or recession won't help.. In that case we try to use the alternate
muscle that can help elevating the lid (frontalis muscle).

26. Treatment
If myasthenia gravis is diagnosed, treatment should
be initiated by a neurologist.
In certain cases, a patient may not want to
undergo surgery. Glasses can be made with
a crutch attachment that can hold up the
lid.

27. 1- If levator function is poor (< 4 mm) or absent, the use of frontalis slings can
achieve desirable postoperative results.
2- A levator advancement or resection results in shortening of the levator aponeurosis and
muscle. The levator can be approached from an anterior or posterior direction.

28. An incision is made by using the natural lid crease, if present, to allow for direct
visualization of the aponeurosis. Once the levator aponeurosis is identified, it is disinserted
from the tarsus, advanced and/or resected, and reattached. The amount of advancement
depends on the degree of ptosis being treated. The aponeurosis also is attached to the
skin to reform the crease.

29. References:
 Kanski's clinical ophthalmology 8th edition
 Medscape.com
 eyewiki.aao.org
 ncbi.nlm.nih.gov

30. Thank you! :)