Ptosis, or abnormally low position of the upper eyelid, can be congenital or acquired. Congenital ptosis is caused by weakness of the levator palpebrae superioris muscle. Acquired ptosis has many causes including neurogenic (e.g. third nerve palsy), myogenic (e.g. myasthenia gravis), aponeurotic/involutional, mechanical (e.g. tumors), or pseudoptosis. Ptosis is evaluated through history, examination of lid position and ocular motility, and measurements including marginal reflex distance 1 (MRD1) and 2 (MRD2). Management depends on the underlying cause and severity of ptosis

1. Ptosis
-Dr. Deepayan Sarkar

2. References
• Kanski Clinical Ophthalmology 8th Edition
• Yanoff Ophthalmology Vol-1, Chapter 86
• Anatomy and Physiology of Eye- Khurana
• Aravind Ophthalmology- N Venkatesh Prajna
• Ptosis Surgery – Arnab Biswas 2010, Jaypee Publication
• JRO Collin- A Manual of Systemic Eyelid Surgery 2006

3. Contents
• Introduction
• Functional Anatomy of Lid
• Classification
• Ptosis Evaluation
• Measurements
• Special Tests
• Management

4. INTRODUCTION:
• Ptosis is abnormally low position of upper eyelid margin determined while the eye is looking
in primary gaze.
• Comes from the Greek word Ptosis meaning fall.
• The upper lid covers 2mm of the superior cornea , more than 2mm drooping of the upper lid
is ptosis.

5. Functional Anatomy of Lid:
Layers of the Eyelid:
1) Skin- The skin covering the eyelids is stratified squamous
epithelium, having fine texture and the thinnest in the body.
2) Subcutaneous tissue- Beneath the skin, containing fibrous
tissue and no fat .It is readily distended by oedema or blood.
3)Layer of striated muscle-
a) Orbicularis Oculi- Orbital part forms the most of the
peripheral fibres of the orbicularis which arise from the anterior
part of the medial palpebral ligament and the adjacent bones.
Palpebral part subdivided into a preseptal and pretarsal portions.
b) Levator Palpebrae Superioris (LPS)

6. • Levator palpebrae superioris (LPS):
– is the primary muscle responsible for lid elevation.
– It arises from the lesser wing of Sphenoid above
the annulus of Zinn and extends forwards over
the cone of eye muscles.
– It inserts into the eyelid and the tarsal plate, a
fibrous semicircular structure which gives the
upper eyelid its shape.
– Two horns of attachment-
Medial horn- passes over the reflected tendon of
superior oblique and fuses with the upper border
of medial canthal tendon.
Lateral horn- Thicker and divides the lacrimal
gland into orbital and palpebral part and inserts
into the superior edge of the lateral canthal
tendon
– The LPS is supplied by the superior
division of the Oculomotor nerve.

7. 4) Submuscular areolar tissue- Layer of loose connective tissue
present between orbicularis muscle and fibrous tissue. The
nerves and vessels of the lid are present in this layer. [Surgical
importance- Local anaesthetic to be instilled in this layer].
5) Fibrous layer- The framework of the lids and consists of a
central thick part of the tarsal plate and peripheral thin part of
septum orbitale.
a) Tarsal plate- The upper tarsus is 10 mm in height and lower
tarsus is 5 mm.; 29 mm in breadth and 1mm thickness.
Septum orbitale and Muller’s muscle are attached at the
superior border of upper tarsus. The orbital septum
,capsulopalpebral fascia and inferior palpebral muscle are
attached to the inferior border of the lower tarsus. Contains
the Meibomian gland which are modified sweat glands and
secreate lipid layer of the tear flim.
a) Septum orbitale- Thin, floating membrane of connective
tissue which takes part in all the movements of the eyelids.

8. 6) Layer of non-striated muscle- Layers of smooth
muscle fibres of Muller’s which lie just deep to septum
orbitale. The Muller’s muscle arise from the inferior
fibres of the LPS in the upper lid and from the expansion
the inferior rectus in the the lower eyelid. Supplied by the
sympathetic nerve fibres.
7) Conjunctiva- The posterior most layer of the eyelid is
formed by the palpebral conjunctiva, which extends from
the mucocutaneous junction at the lid margin to the
conjunctival fornix.

9. Classification of Ptosis:
A)Congenital
B) Acquired:
1)Neurogenic
2) Myogenic
3)Aponeurotic/Involutional
4) Mechanical
C) Pseudoptosis

10. Congenital Ptosis:
• It is due to congenital weakness (maldevelopment) of LPS.
• Pathogenesis- Failure of neuronal migration/development of muscle
and its sequel.
1. Simple congenital ptosis
– not associated with any other anomaly.
2. Congenital ptosis with associated weakness of superior rectus
muscle.
• Features-
1) Unilateral/Bilateral ptosis.
2) Absent upper lid crease.
3) Poor Levator function.
4) In downgaze the ptotic lid is higher than the normal because of
poor relaxation of the levator muscle (contrast to acquired
ptosis).

11. 3. BPES syndrome-
• Blepharophimosis, Ptosis, Epicanthus inversus syndrome.
• It is Autosomal dominant in inheritance caused by mutation of
FOXL2 gene on Chromosome 3.
• Manifests with poor levator action ,telecanthus, small palpebral
fissure and other facial anomalies (tarsal plate hypoplasia, poorly
developed nasal bridge, low set ears) may be present.
• BPES type 1 (with premature ovarian failure)
• BPES type 2 (without ovarian failure)
• Treatment-
- Staged approach
- Mustarde’s double Z plasty or Y-V plasty with transnasal wiring is
done as the primary procedure.- Correction of telecanthus is achieved
and well as deep placement of medial canthus
- Brow suspension is carried out after 6 months of first procedure for
correction of Ptosis

12. 4) Marcus Gunn jaw winking phenomenon-
-It is seen in 5% on cases of congenital ptosis.
- A branch from mandibular division of 5th cranial nerve is
misdirected to the levator muscle.
- Signs-
1) Retraction of the ptotic lid in conjunction with stimulation of
ipsilateral pterygoid muscle by chewing, opening mouth or
contralateral jaw movement.
2) Less common stimuli to winking include jaw protrusion, smiling,
swallowing and clenching of teeth.
3) It doesnot improve with age, although patient may learn to
it.
- Treatment-
1) Mild case- Reasonable levator function of 5mm or better, little
synkinetic movement may be treated with unilateral levator
advancement.
2) Moderate case- U/L levator disinsertion with frontalis suspension.
3) Bilateral case- B/L levator disinsertion with bilateral brow
suspension

13. Acquired Ptosis :
1) Third nerve palsy- LPS is supplied by the Oculomotor nerve, paresis of
the superior division of the 3rd nerve. It is associated with Superior rectus
palsy. Isolated LPS palsy is rare.
Signs-
a) Defective ocular movements.
b) Pupil dilated.
c) U/L or B/L ptosis
2) Third nerve misdirection syndrome- Congenital or aberrant
regeneration of 3rd nerve after palsy. Rare, Unilateral, Bizzare movement
of upper lid accompany eye movement.
T/t- Levator disinsertion and brow suspension
A) Neurogenic

14. 3)Horner’s syndrome:
a) First order/Central lesion- Sympathetic supply from posterior
hypothalamus to terminate in cilio-spinal centre of Budge(C8-
T2).
-Stroke, Brainstem tumor, Syringomylia, Wallenberg syndrome,
Cervical cord lesion.
b) Preganglionic/Second order- From cilio-spinal centre of Budge
(C8-T2) to superior cervical ganglion in neck.
-Pancoast tumor, Carotid-aortic aneurysm & dissection, Thoracic
spinal cord lesion, Thyroid tumor.
c) Postganglionic/Third order- Ascends along the internal carotid
artery to enter the cavernous sinus where it joins the ophthalmic
division of the Trigeminal nerve. Enters dilator pupillae by
Nasociliary nerve.
-Internal carotid artery dissection, Nasopharyngeal tumours,
Cavernous sinus mass, Otitis media

15. Presentation-
1) Mild ptosis – Weakness of Muller’s Muscle.
2) Miosis- Unopposed action of sphincter pupillae with resultant
anisocoria.
3) Anisocoria accentuates on dimlight examination.
4) Hypochromic heterochromia- long standing cases.
5) Reduced ipsilateral sweating- Pilosebaceous sympathetic supply is
diminished.
Tests to identify-
1) Apraclonidine (0.5% or 1%) – Horner pupil dilates, normal pupil
doesn’t.
2) Cocaine (4%)- Normal pupil dilates, Horner doesn’t.
3) Phenlyepherine- Postganglionic Horner’s pupil dilate; central and
pre-ganglionic doesn’t.
4) Hydroxyamphetamine-Normal or Preganglionic Horner’s pupil dilate
but Postganglionic pupil doesn’t.
Treatment- Identify the cause and treat.

16. It is due to acquired disorders of the LPS muscle or of the myoneural junction.
1) Myasthenia Gravis- It is an autoimmune disease in which anti-bodies mediate damage and
destruction to acetylcholine receptors in striated muscles, causing weakness and fatigability.
Symptoms-
a) Painless fatigue in conjunction with ptosis and diplopia.
b) Dysphagia, Dysarthria, Dyspnea.
Ocular Signs-
a) Ptosis- Insidious, Bilateral, typically worse by the end of the day, worse on prolonged (60sec)
upgaze due to fatigue, Cogan twitch sign.
b) Diplopia- Frequently vertical nystagmus although any extraocular muscle can be affected.
c) Nystagmoid movement- Present in extreme of gaze.
Investigations-
a) Ice-pack test- Improvement of Ptosis after application of icepack for 2 mins (as cold inhibits
breakdown of acetylcholine by acetylcholine esterase)
b) Antibody testing- AchR (Ach receptor) antibody , MuSK protein antibody
B) Myogenic :

17. c) Edrophonium(Tensilon) test- Edrophonium chloride inhibits acetylcholinesterase,
thereby prolonging the presence of acetylcholine at the neuromuscular junction. This
results in enhanced muscle strength.
• In ptosis, a positive test is the elevation of eyelids in 2-5 minutes post
adminstration of Tensilon.
• A negative response is no improvement within 3 minutes.
Tensilon test has a relatively low sensitivity, approximately 60% for MG.
• False positive results occur in patients with
– Lambert-Eaton Myasthenic Syndrome (LEMS),
– Amyothrophic Lateral Sclerosis (ALS), and
– Localized intracranial mass lesions.
Before After

18. d) Electromyography- Shows impaired nerve-muscle conduction.
e) Muscle Biopsy demonstrates neuromuscular junction antibody.
f) Thoracic imaging- to look for thymoma.
Treatment-
Pyridostigmine with combination of steroid and azathioprine.
Intravenous immunoglobulins.

19. 2) Lambert-Eaton Syndrome- Antibodies are present against the calcium channel on nerve
endings which ultimately inhibits ACH secreation.
Ocular symptoms-
Ptosis, Diplopia
Ocular signs-
Ptosis decreases after prolonged (60sec) upgaze. (contrary to Myasthenia)
Treatment- Steroids, Azathioprine, Immunoglobulins.

20. 3) Myotonic Dystrophy- It is characterized by delayed muscular
relaxation after cessation of voluntary effort.
2 types-
a) Dystrophia myotonica 1 (DM1)- Mutation of dystrophia myotonica
protein kinase gene DMPK.
b) Dystrophia myotonica 2 (DM2)- Proximal muscle myopathy, involves
gene CNBP.
Ocular features-
a) Ptosis
b) Hypermetropia
c) Cataract formation (Christmas tree pattern)
d) Myotonic faces
Investigation- Genetic testing
Treatment- Eyelid crutches, Frontalis suspension

21. 4) Ocular Myopathies-
a) Isolated CPEO- Ptosis is usually the first sign is bilateral and
asymmetric. Pupil is not involved, external ophthalmoplegia is
typically symmetrical . EMG study confirms diagnosis.
Surgical correction may improve head posture but doesnot restore
normal lid movement.
b) Kearns-Sayre syndrome- Mitochondrial myopathy associated with
mitochondrial DNA deletions. Clinical triad of CPEO, cardiac
abnormalities and typical salt-pepper retinopathy at the macula.
Presents with mild visual impairement, night blindness.
Genetic testing , CSF study, Histology studies confirm diagnosis.
c) Oculopharyngeal dystrophy- Caused by mutation of PABPN1. It is a
nucleotide repeat disorder, inheritance is AD or AR. Treatment is
palliative.

22. Aponeurotic/Involutional :
-Age related condition by dehiscence, disinsertion or
stretching of the levator aponeurosis limiting the
transmission of force from normal levator muscle to the
upper lid.
-Due to fatigue of the Muller’s muscle ptosis frequently
increases during end of the day.
-Usually bilateral.
-High upper lid crease.
-Good levator function

23. Mechanical Ptosis-
• Mechanical Ptosis is the result of impaired mobility of the
upper lid.
1) Tumors-
a) Bening tumor- Neurofibroma/Haemangioma
b) Malignant tumor- Basal cell carcinoma (BCC), Squamous cell
carcinoma (SCC), Malignant melanoma,
Rhabdomyosarcoma.
c) Metastatic lesion- from breast or lung.
d) Sinus extension- mucocoele of frontal sinus.
2) Blepharochalasis- Hereditary with recurrent attacks of severe
oedema and residual damage of tissue.
3) Intracranial mass extension like chordoma
4) Miscellaneous- Contact lens migration, repeated cicatricial
conjunctivitis or surgical trauma to superior fornix.

24. • Pseudoptosis is the appearance of ptosis in the absence of
levator abnormality.
• Pseudoptosis to be evaluated on inspection.
• Its common causes are:
– Microphthalmos
– Anophthalmos
– Enophthalmos
– Phthisis bulbi
– Double elevator palsy
– Blepharospasm
– Dermatochalasis
– Brow Ptosis
Pseudoptosis :

25. Evaluation of Ptosis :
History-
• Ptosis
– Age of onset
– Duration
– One/both eye
– Diurnal variability
• Associated history :
– Diplopia
– Dysphagia
– Muscle weakness
• Vision
• Associated jaw
movements
– Abnormal ocular movements
– Abnormal head posture
• History of
– Trauma or previous surgery
– Poisoning
– Use of steroid drops
• Previous photographs help to correlate progression of ptosis
• Is there a family history of ptosis or of other muscle weakness

26. Ocular Examination:
• U/L or B/L
• Grading of Ptosis-
2mm of less- Mild Ptosis
3mm- Moderate Ptosis
4mm or more- Severe Ptosis
• Head Posture:
– Chin elevation as the ptosis is minimum in downgaze in a patient with congenital ptosis is also one
of the indications for surgery especially in the pediatric age group.
• Ocular Motility:
– Important in myogenic ptosis,
– Presence of strabismus, especially vertical strabismus entails that it be corrected prior to the correction
of the ptosis.
• Visual acuity
– Best-corrected visual acuity should be assessed to record any amblyopia if present, especially in cases
of congenital ptosis.
• Pupillary Examination:
– To diagnose Horner’s Syndrome. (Miosis)
– Involvement in a case of third nerve palsy. (Mydriasis)

27. Measurements in case of Ptosis:
1) Marginal Reflex Distance 1(MRD1) -
• It is the distance between centre of the lid margin of the
upper lid and the light reflex on the cornea in primary
position.
• If the lid margin is above the light reflex, MRD1 has a positive
value.
• If the lid margin is below the light reflex, MRD1 has a
negative value(measured as amount of lid excursion till the
central corneal light reflex is seen).
• Normal value- 4-5mm

28. 2) Marginal Reflex Distance 2 (MRD2)-
• It is the distance from corneal light reflex to the lower lid
margin.
• Measured by scale, with patient looking in primary gaze.
• MRD2 normal values 3.5-4.5mm

29. 3) Palpebral Fissure Height-
• It is the distance between the upper and lower lid margin in the pupillary
plane.
• It is the summation of the MRD 1 & MRD 2.
• Normal value:
Males- 7-10 mm
Females- 8-12 mm

30. 4) Levator Function –
Normal- 15mm or more
Good- 8mm -15mm
Fair- 5-7mm
Poor- Less than 5mm
a) Berke’s Method- Measures excursion of the upper lid from extreme
downgaze to extreme upgaze with action of frontalis blocked by thumb.
Procedure-
• Patient positioned against the wall.
• Patient is asked to look in downgaze.
• Action of Frontalis blocked by thumb.
• Patient asked to look up.
• Amount of lid excursion is measured

31. b) Putterman’s method –
• Measurement of distance between the middle of the upper lid margin to
the 6ó clock limbus in extreme upgaze.
• This is also known as Margin Limbal Distance
• Normal is 9mm
• Amount of levator resection required:
- The difference of MLD of two sides in unilateral cases.
- The difference with normal value (9mm) in bilateral cases multiplied by 3

32. c) Iliff Test-
• Applicable in children below age of 1 year.
• The upper eyelid of the child is everted as the
child looks down, if levator action is good the
eyelid reverts back of its own.

33. 5) Margin crease distance (MCD)-
• The height of the crease on the normal side should be measured and
compared with the ptotic eyelid in downgaze.
• It signifies the insertion of the LPS on the tarsal plate.
• Normal value-
Male- 10mm
Female- 8mm
• Absence of lid crease is seen in congenital ptosis.
• High lid crease is seen in aponeurotic ptosis.
• The lid crease also helps in planning the incision during surgery.

34. 6) Pretarsal show-
It is the distance between the lid margin and the skin fold with the eyes in
position.

35. Special Tests:
1) Bell’s Phenomenon-
• It is upward rotation of the eyeball on closure of the eyes.
• Confirmation of Bell’s phenomenon is important as it avoids
the risk of post-operative exposure keratopathy.
• Grading:
- More than 2/3 rd of cornea under upper lid- Good
- 1/3rd-2/3rd- Moderate
- <1/3rd -Poor

36. 2) Fatigability test-
• Patient is asked to look up without blinking for 60 seconds.
• The ptosis is measured again.
• An increase of Ptosis is seen in Myasthenia Gravis.
• A decrease of Ptosis is seen in Lambert Eaton Syndrome.

37. 3) Cogan twitch sign-
• Seen in Myasthenia Gravis.
• Patient asked to look in downgaze for sometime and then asked to
look up, the ptotic lid overshoots, this is Cogan twitch sign.

38. 4) Ice-pack test
Ice pack applied over the ptotic eyelid for 1 min leads to reduction of
ptosis in Myasthenia Gravis.
5) Similarly Edrophonium Test is done in Myasthenia Gravis.

39. Management :
• Non-surgical :Rehabilitive eye crutches, attached to spectacle frames.
Used in neurogenic and myogenic ptosis in very young children, in
old patients not willing surgery and patients with poor Bell’s. Long
hours of use can lead to dry eye.
• Surgical : Definitive management
• When to operate:
1) Risk of amblyopia- Should be done in children at an early age by
3-4 years.
2)Cosmetic concern – Can be operated at any age.
3) Squint with ptosis- Squint to be operated first followed by ptosis
repair.
4) In BPES syndrome- Blepharophimosis, epicanthus to be
operated first.

40. Planning of surgical procedure:
a) Ptosis is unilateral/bilateral.
b) Severity of Ptosis.
c) Levator action.
d) Bell’s phenomena.
e) Dry eye workup.
f) Presence of abnormal ocular movements, jaw winking phenomena or
Levator
function
>10mm <10mm
Degree of Ptosis
<2mm >2mm
Fasanella-Servat
operation
Aponeurosis
Surgery
Levator
function
>4mm <4mm
Levator
Resection
Brow
Suspension

41. Tooth forceps, Plain forceps ,Chalazion
clamp, Lid guard,
Eye speculum,
Caliper ruler mm/inch,
A No. 15 & 10 blade
Skin hooks
Cat’s paw retractor ,Desmarre’s retractor
Muscle hook ,Suction cannulae ,Punctum
dilator Lacrimal probe
Micro needle holder
Babcock needle holder
Castroviejo needle holder
Stevens scissors and Westcott's scissors Tenotomy scissors
Lim tooth forceps
Basic Surgical
Instruments
Required:

42. Congenital Ptosis surgery : Levator Resection—Congenital Ptosis (Beard)
Degree of Ptosis Levator Function Resection
Mild (<2 mm) >10 mm Small (10-13 mm)
Moderate (3 mm) >8 mm <8 mm Moderate (14-17 mm)
Large (18-22 mm)
Severe (>4 mm) <5 mm Maximum (> 23 mm)
• The Levator is fibrous, dysplastic and contains
fibro-fatty tissue.
• LPS resection is the preferred surgery when
reasonable Levator function is present
• In severe ptosis , frontalis sling surgery is done.
• Surgery is preferred before the age of 5 years.
• Earlier surgery is done in case of ptosis causing
block in the pupillary axis or severe bilateral
ptosis or chin-up head position.

43. Modified Fasanella Servat :
• Mild Ptosis (<2mm or less)
• Levator action(>10mm)
• Well defined lid fold- no excess skin
• Principle of Surgery- Excision of upper part of Tarsus, Conjunctiva and inferior part of
Muller’s muscle and shortening of posterior lamellae of upper lid.
• 2 mm tarsectomy done for every 1mm of Ptosis
Surgical steps:
3 Sutures (4-0 silk) passed close to the folded superior margin
of the tarsal plate at middle, lateral and medial one-third of the
lid.
3 Corresponding sutures (4-0 silk) are placed close to the
everted lid margin starting from conjunctival aspect near the
superior fornix in position corresponding to the first 3 sutures.

44. Proposed incision is marked on the tarsal plate
such that an uniform piece of tarsus ,
decreasing gradually from the periphery is
excised.
Dissection with monopolar cautery
Full thickness excision of the marked
tarsal plate.

45. Tarsal wound closed with 6-0
catgut continuous running suture
and knots exteriorised
Traction sutures removed

46. Levator Resection :
• Mild/moderate/severe ptosis
• Levator action >4mm
Surgical Steps :
Marking of upper lid crease incision
Central sutures placed, incision given along
skin and orbicularis is made along the
markings

47. Inferior skin and orbicularis
dissected from tarsal plate.
Orbital septum incised, preaponeurotic fat pad is
visualized, Whitnall’s ligament is visualized(Whitnall’s
ligament to be preserved), fibres of aponeurosis are cut
from insertion in the inferior half of the anterior of
tarsus.
Levator is freed from adjoining structures .
.

48. A double armed 5-0 vicryl is passed through centre
of the tarsal plate by partial thickeness bite, it is then
passed through the levator aponeurosis at the
height judged by pre-op evaluation.
2 more double armed vicryl 5-0 sutures are passed
through tarsus about 2mm from the upper border in
the centre and the junction of central third with
medial and lateral third.

49. These sutures passed through levator and
intra-op assessment made. Excess levator is
excised.
Skin closed with 6-0
Silk/Prolene

50. Tarso-Frontalis Sling :
• Severe Ptosis
• Levator action <4mm
• Jaw winking phenomenon or BPES syndrome
• Marcus –Gunn Ptosis
Performed with-
1) Non-absorbable sutures like Prolene, ePTFE (extended polytetrafluroethylene)
2) Autologous Fascia Lata/ Temporalis Fascia

51. Surgical Steps:
Eyelid incisions marked over upper eye lid 1cm
apart, 3-4mm from lash line.
Central brow incision 10-12mm above
superior border of eyebrow.
Stab incision made with blade.
Needle passed through silicon rod passed through
sub orbicularis plane from central brow incision to
lateral brow incision

52. Needle passed through lateral
stab incision
Needle taken out through medial stab
incision
And out through the central brow incision

53. Silicon tube fed through the ends of the silicon tube and
brought out of the central brow incision
Silicon sleeve adjusted to adjust the height of the eyelid.
Silicon sleeve transfixed with 6-0 prolene sutures
Wound Closure with 6-0 prolene

54. Complications of Ptosis Surgery:
1) Overcorrection
2) Undercorrection
3) Lid contour abnormality
4) Lagophthalmos
5) Lid crease and fold assymetry
6) Exposure Keratopathy
7) Infection
8) Haemmorhage

55. Recent Advances
Dynamic Frontalis muscle flap- tunneled into the eyelid that directly attaches the
tarsal plate.

56. Thank You