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HOW TO EVALUATE ITS CLINICALASPECT
Dr. Neeraj Agarwal
GMC, KOTA
 Blepharoptosis is derived from the greek word
blepharon=eyelid and ptosis= falling.
 So blepharoptosis means drooping o...
CLASSIFICATION
 CONGENITAL
 ACQUIRED
CONGENITAL
 Simple ptosis
 With SR weakness
 With blepharophimosis syndrome
 Synkinetic ptosis – Marcus Gun Jaw Winkin...
ACQUIRED PTOSIS
 Neurogenic- 3rd nerve palsy, horner syndrome.
 Myogenic- myasthenia gravis, Myotonic
dystrophy.
 Apone...
Pseudoptosis
 Ipsilateral hypotropia
 Enopthalmos
 Dermatochalasis
 Double elevator palsy
 Brow ptosis
 Blepharospas...
EVALUATION OF PTOSIS
 When patient enters examination room,
observation of the head posture with chin
elevation and front...
HISTORY
 Age of onset
 Duration
 Unilateral/bilateral
 Weather ptosis worsen through the day
 Diplopia
 Muscle weakn...
 Presence of any aberrant lid movements
 Weather eye movements are impaired
 Past medical history
 Current medications...
EXAMINATION
 Head posture
 Periocular fullness
 Frontalis overaction
 Scar mark
 Lid skin laxity
 Telecanthus, epica...
 Ocular Motility:
 Importance in myogenic ptosis,
 To R/O 3rd nerve palsy
 presence of strabismus, especially vertical...
 Refraction- Cycloplegic test refraction is
indicated in all children with ptosis since it is
known that a significant nu...
MEASUREMENTS
 Margin reflex distance 1(MRD 1)- After
shining the torchlight in the patient eye, the
distance between the ...
Marginal reflex distance
• Distance between upper lid
margin and light reflex (MRD)
• Mild ptosis (2 mm of droop)
• Modera...
 Margin reflex distance 2 (MRD 2)- the
distance of corneal light reflex to the centre of
the lower eyelid margin in prima...
 Margin reflex distance 3(MRD 3)- the
distance between the corneal light reflex and
the centre of upper eyelid margin in ...
 Palpebral fissure height (PFH)- MRD1 + MRD2.
 Central palpebral fissure height is measured in
primary gaze and compared...
 Also it is important to measure the PFH in
downgaze. As reduced ptosis/ lid lag is seen in
congenital ptosis as the dyst...
Upgaze accentuate ptosis
Downgaze  lid
lag
 Margin crease distance(MCD)- it is an
important anatomical landmark, which give
clue to levator action.
 It is measured...
 An absent lid crease is often accompanied
by poor levator function.
 If a lid crease is present, but higher than
normal...
 MARGIN LIMBAL DISTANCE- it gives the
degree of loss of Levator action.
 It is measured as the distance between the
cent...
Levator function test- Excursion of
upper eyelid from extreme downgaze to
extreme upgaze is a measure of LPS
function, ne...
 Grading of levator function-
 >15mm= normal
 >8 mm= good
 5-7 mm= fair
 <4 mm= poor
ILLIF’s test
 Used in children
 Pt upper lid is everted in downgaze. On
looking up, the lid should return to normal
posi...
Marcus gunn jaw winking
phenomenon
 Marcus Gunn jaw-winking phenomenon is the most
common form of congenital synkinetic n...
Grading of marcus gunn
phenomenon
 Mild- maximum elevation of ptotic eyelid non-
ptotic position
 Moderate- maximum elev...
 BELL’S PHENOMENON- the eyes moves
generally upwards and outwards on eyelid
closure. It is extremely important in assessi...
BELLS PHENOMENON
 GRADING-
good= >2/3 of cornea disappears
fair= 1/3 – 2/3 of cornea disappears
poor= <1/3 of cornea disa...
BELLS PHENOMENON
 Corneal sensation- always check before
planning the surgery.
 Schirmers test – to rule out dry eye disease
 Pupillary ...
 Look for any associated mass lesion causing
mechanical ptosis
 Cogan's lid twitch sign- may be seen when the
patient first looks down for a short period and
then look back to primary ...
 Phenylephrine test- The function of muller’s is
tested by applying drops of 10% phenylephrine
to the eye on the side of ...
Edrophonium test
• Measure amount of ptosis or
diplopia before injection
• Inject i.v. atropine 0.5 mg
• Inject i.v. test ...
ICE TEST
 An ice pack is applied to the affected upper
eyelid for 5 minutes. A positive test is the
improvement of ptosis...
Ice test
 Photographic documentation- it is the most
important aspect of ptosis evaluation. Review
of old photographs gives clue t...
So we should examine case of ptosis
carefully before proceeding for surgical
management, to avoid any post operative
surp...
THANK YOU
Ptosis
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Ptosis

  1. 1. HOW TO EVALUATE ITS CLINICALASPECT Dr. Neeraj Agarwal GMC, KOTA
  2. 2.  Blepharoptosis is derived from the greek word blepharon=eyelid and ptosis= falling.  So blepharoptosis means drooping of upper eyelid.  Blepharoptosis often abbreviated as ptosis.  Normally upper eyelid covers 1/6th of cornea i.e. 2mm  Therefore in ptosis it covers more than 2mm.
  3. 3. CLASSIFICATION  CONGENITAL  ACQUIRED
  4. 4. CONGENITAL  Simple ptosis  With SR weakness  With blepharophimosis syndrome  Synkinetic ptosis – Marcus Gun Jaw Winking ptosis, Misdirected third nerve syndrome
  5. 5. ACQUIRED PTOSIS  Neurogenic- 3rd nerve palsy, horner syndrome.  Myogenic- myasthenia gravis, Myotonic dystrophy.  Aponeurotic- involutional, post surgical  Mechanical- tumour, swelling.
  6. 6. Pseudoptosis  Ipsilateral hypotropia  Enopthalmos  Dermatochalasis  Double elevator palsy  Brow ptosis  Blepharospasm  Contralateral lid retraction  Contralateral exopthalmos
  7. 7. EVALUATION OF PTOSIS  When patient enters examination room, observation of the head posture with chin elevation and frontalis overaction indicate severe ptosis.
  8. 8. HISTORY  Age of onset  Duration  Unilateral/bilateral  Weather ptosis worsen through the day  Diplopia  Muscle weakness  trauma/ surgery  lid edema  previous ptosis surgery
  9. 9.  Presence of any aberrant lid movements  Weather eye movements are impaired  Past medical history  Current medications  Family history  Old photographs
  10. 10. EXAMINATION  Head posture  Periocular fullness  Frontalis overaction  Scar mark  Lid skin laxity  Telecanthus, epicanthus inversus
  11. 11.  Ocular Motility:  Importance in myogenic ptosis,  To R/O 3rd nerve palsy  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
  12. 12.  Refraction- Cycloplegic test refraction is indicated in all children with ptosis since it is known that a significant number have anisometropia primarily due to astigmatism on the ptotic side.  Any significant refractive error should be corrected
  13. 13. MEASUREMENTS  Margin reflex distance 1(MRD 1)- After shining the torchlight in the patient eye, the distance between the corneal light reflex to the centre of the upper lid margin is measured.  Normal value is 4- 4.5mm.
  14. 14. Marginal reflex distance • Distance between upper lid margin and light reflex (MRD) • Mild ptosis (2 mm of droop) • Moderate ptosis (3 mm) • Severe ptosis (4 mm or more)
  15. 15.  Margin reflex distance 2 (MRD 2)- the distance of corneal light reflex to the centre of the lower eyelid margin in primary gaze.  Normal value is 5- 5.5mm
  16. 16.  Margin reflex distance 3(MRD 3)- the distance between the corneal light reflex and the centre of upper eyelid margin in extreme upgaze.
  17. 17.  Palpebral fissure height (PFH)- MRD1 + MRD2.  Central palpebral fissure height is measured in primary gaze and compared with the normal eye in unilateral ptosis.
  18. 18.  Also it is important to measure the PFH in downgaze. As reduced ptosis/ lid lag is seen in congenital ptosis as the dystrophic muscle neither contracts nor relaxes.
  19. 19. Upgaze accentuate ptosis Downgaze  lid lag
  20. 20.  Margin crease distance(MCD)- it is an important anatomical landmark, which give clue to levator action.  It is measured with patient looking down, distance from the central eyelid margin to the most prominent lid crease.  Normal value in Men 5-7mm, women 8-10mm  Crease is absent in congenital ptosis and higher in aponeurotic ptosis.
  21. 21.  An absent lid crease is often accompanied by poor levator function.  If a lid crease is present, but higher than normal and if there is a deeper upper lid sulcus on that side these should be noted as signs of levator disinsertion.
  22. 22.  MARGIN LIMBAL DISTANCE- it gives the degree of loss of Levator action.  It is measured as the distance between the centre of upper lid margin to 6o’clock limbus in extreme upgaze  Normally it is 9mm.
  23. 23. Levator function test- Excursion of upper eyelid from extreme downgaze to extreme upgaze is a measure of LPS function, negating the action of frontalis muscle (Berke’s method).
  24. 24.  Grading of levator function-  >15mm= normal  >8 mm= good  5-7 mm= fair  <4 mm= poor
  25. 25. ILLIF’s test  Used in children  Pt upper lid is everted in downgaze. On looking up, the lid should return to normal position if levator action is good.
  26. 26. Marcus gunn jaw winking phenomenon  Marcus Gunn jaw-winking phenomenon is the most common form of congenital synkinetic neurogenic ptosis.  The unilaterally ptotic eyelid elevates with jaw movements due to cross innervations between oculomotor nerve and mandibular branch of trigeminal nerve  This synkinesis is best demonstrated by having the patient move the jaw the opposite side.  The internal pterygoid may be involved, but rarely.
  27. 27. Grading of marcus gunn phenomenon  Mild- maximum elevation of ptotic eyelid non- ptotic position  Moderate- maximum elevation goes upto superior limbus  Severe- maximum elevation beyond the superior limbus with scleral show
  28. 28.  BELL’S PHENOMENON- the eyes moves generally upwards and outwards on eyelid closure. It is extremely important in assessing post-operative corneal complications.  Poor bells phenomenon invariably warrants under correction.
  29. 29. BELLS PHENOMENON  GRADING- good= >2/3 of cornea disappears fair= 1/3 – 2/3 of cornea disappears poor= <1/3 of cornea disappears  VARIANT- Inverse- upward & inward Reverse- downward & outward Preverse- different directions
  30. 30. BELLS PHENOMENON
  31. 31.  Corneal sensation- always check before planning the surgery.  Schirmers test – to rule out dry eye disease  Pupillary abnormalities- miosis in horner’s syndrome mydriasis in 3rd nerve palsy.
  32. 32.  Look for any associated mass lesion causing mechanical ptosis
  33. 33.  Cogan's lid twitch sign- may be seen when the patient first looks down for a short period and then look back to primary position.  The upper eyelid elevates excessively during this upward movement.  This is interpreted as transient improvement in lid strength after rest of the levator in downgaze, followed by droop in the primary position as the levator fatigues
  34. 34.  Phenylephrine test- The function of muller’s is tested by applying drops of 10% phenylephrine to the eye on the side of blepharoptosis.  A rise in the MRDl of 1.5 mm or greater is considered a positive test. This indicates that Müller's muscle is viable. so operation to resect muller’s muscle and conjunctiva can relieve blepharoptosis.
  35. 35. Edrophonium test • Measure amount of ptosis or diplopia before injection • Inject i.v. atropine 0.5 mg • Inject i.v. test dose of edrophonium (0.2 ml-2 mg) •inject remaining (0.8 ml-8mg) if no hypersensitivity Before injection Positive result
  36. 36. ICE TEST  An ice pack is applied to the affected upper eyelid for 5 minutes. A positive test is the improvement of ptosis by > 2mm or more.  This transient improvement in ptosis is due to the cold decreasing the acetylcholinesterase break-down of acetylcholine at the neuromuscular junction. More acetylcholine collects in the junction and therefore increases the muscle contraction.
  37. 37. Ice test
  38. 38.  Photographic documentation- it is the most important aspect of ptosis evaluation. Review of old photographs gives clue to the duration and nature of ptosis.
  39. 39. So we should examine case of ptosis carefully before proceeding for surgical management, to avoid any post operative surprise.
  40. 40. THANK YOU
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