This document discusses ptosis (drooping of the upper eyelid) including its definition, evaluation, classification, and treatment options. Ptosis is evaluated based on 5 clinical measurements including margin-reflex distance, vertical palpebral fissure height, upper eyelid crease position, levator function, and presence of lagophthalmos. The most common form is aponeurotic ptosis which is caused by stretching or dehiscence of the levator aponeurosis. Treatment depends on the degree of ptosis and levator function, and may include levator resection, Muller's muscle shortening, or brow suspension. Levator resection is suitable for mild ptosis with good levator function,

1. Dr Mubashir Hassan
Post graduate resident
Orthopedic Surgery
Sheikh Zayed Hospital Rahim
Yar Khaan

2. Ptosis (Blepharoptosis)

3. Definition
Ptosis ( in greek means to fall) is the
abnormal drooping of the upper
eyelid. Normally upper lid covers
about upper one sixth of the cornea
i.e about 2mm. Therefore in ptosis it
covers more than 2 mm.

9. Evaluation
• History taking
• Physical Exam
• Additional Considerations
• Ancillary Tests

10. 5 clinical measurement
• Margin-reflex distance
• Vertical palpebral fissure height
• Upper eyelid crease position
• Levator Funtion (upper lid excursion)
• Presence of lagophthalmos

12. Margin-reflex
distance
• MRD1 : distance from the upper eyelid
margin to the corneal light reflex in
primary position
• MRD2 : distance from the lower eyelid
margin to the corneal light reflex in
primary position
• MRD1=Single most important
measurement
• MRD1+MRD2=Palpebral fissure

13. Vertical
Palpebral
Fissure
• Widest point between the lower eyelid
and the upper eyelid
• Patient is fixing on a distant object in
primary gaze

14. Upper
Eyelid
Crease
Position
• Distance from the upper eyelid crease to
eyelid margin is measured
• Insertion of fibers from the levator
muscle into the skinupper eyelid crease
• 8-9 mm in males and 9-11 mm in females
• Upper eyelid crease is typically lower or
obscured in the Asian eyelid, with or
without ptosis

16. Levator Function
• Upper eyelid excursion
from downgaze to
upgaze with frontalis
muscle function
negated

17. Lagophthalmos • Note the gap between the eyelids in mm
• Record the tear film quantity and quality

18. Ancillary Test
• Visual field testing with the eyelids untaped vs
taped  improvement indicates better vision
with eyelid surgery
• Pharmacologic testing, pupillary evaluation in
light and dark, reverse ptosis of the lower
eyelid

19. PTOSIS
BY COURSE
Traumatic Mechanical Myogenic Aponeurotic Neurogenic
BY ONSET
CONGENITAL Acquired
Classification

21. Aponeurotic ptosis
• Acquired aponeurotic ptosis is the most common
form of ptosis
• Stretching or dehiscence of the levator
aponeurosis or disinsertion from its normal
position
• Common causes are involutional attenuation or
repetitive traction on the eyelid
• Frequent eye rubbing or prolonged use of rigid
contact lenses
• Exacerbated by intraocular surgery or eyelid
surgery

23. characteristic • High or absent upper eyelid crease
secondary to upward displacement or
loss of the insertion of the levator
fibers into the skin
• Thinning of the eyelid superior to the
upper tarsal plate is often an
association finding
• Levator function is normal (12-15mm)
• Worsen in downgaze
• Limit the superior visual field

25. MECHANICAL PTOSIS
• Refers to the condition in which an eyelid or
orbital mass weighs or pulls down the upper
eyelid, resulting in inferior displacement
• Plexiform neurofibroma
• Hemangioma
• Acquired neoplasm
• Large chalazion
• Postsurgical, posttraumatic edema
• Etc…….

26. TREATMENT

27. TREATMENT
1. Levator aponeurosis repair
2. Levator resection
3. Muller’s muscle shortening
4. Brow suspension

28. Key factor
• The amount of ptosis and the function of the levator
muscle are the key factors
• Levator resection is suitable for any amount of ptosis
with a levator function better than 4 mm
• Muller’s muscle shortening:The Fasanella-Servat
operation was the first operation of this type. These
operations are appropriate only if the levator function is
at least 10 mm and there is a maximum of 2 mm of
ptosis. The instillation of phenylephrine 10% (or 2.5%)
will restore the affected lid to its normal position in
suitable patients.
• Brow suspension is the only procedure which will give a
lasting correction if the levator function is 4 mm or less.

29. Consideration Procedure of choice
LF>4mm Levator resection
LF>10mm, ptosis<2mm, response to
phrenylnephrine stimulation
Muller’s muscle shortening
LF<4mm Brow suspension

30. Levator Aponeurosis repair
• Choice of approach to the levator The anterior (skin) approach
is familiar, it allows skin to be excised and it leaves the
conjunctiva intact. The posterior (conjunctival) approach,
although less familiar at first, allows more postoperative
control of the lid height.
• Anterior vs Posterior levator aponeurosis repair

31. Anterior Levator Aponeurosis
repair

32. Anterior Levator Aponeurosis
repair

33. Anterior Levator Aponeurosis
repair

34. Anterior Levator Aponeurosis
repair

35. Anterior Levator Aponeurosis
repair

36. Levator resection
• Remember that levator resection can lead to change in height of eyelid
within first 6 weeks
• Rule of thumb lid may rise 1-2 mm if LF > 7 mm and may drop 1-2 mm if
LF<7mm
• Beard’s recommended figures for congenital ptosis give some guidance to
predict final result of surgery

43. Muller’s muscle shortening
• If phenylnephrine test is strongly positive ( restoring the
affected lid to its normal position) Mullerectomy is highly
recommended
• 1.Measure MRD1
• 2.Instill phenylnephrine 10% into superior fornix of the eye
with ptosis (If cardiac condition is presented
phenylnephrine 2.5% may be used instead)
• 3.Wait for 5 minutes
• 4.measure MRD1
• If MRD1 improves after phenylnephrines test then this is
positive result
• And an improved MRD1 can indicate the length of muller’s
muscle and conjunctiva to be resected

44. Type of response suggestion
Normal level Resect 8 mm
Higher than desired level Resect 6.5-8 mm
Lower than desired level Resect 8-9.5 mm
Little response or none Do something else

46. Muller’s muscle and conjunctiva shortening
without tarsal plate excision (Open Technique)

48. Frontalis/Brow suspension
• Children<4yrs  FOX procedure (for later surgery if
ptosis recur)
• Older children and adults  Crawford method
• If unilateral ptosis bilateral brow suspension is still
recommended to maintain indifferent movement
• If one eye is good and one eye is not good weaken
the one with good LF is suggested
• Material= autogenous fascia lata is the best material
when available
• If not available silicone is prefered,Alloderm and
Frozen dura matter may be used

52. alternative

55. Medical therapy
Patients with myasthenia gravis may improve with medical
treatment. Sympathomimetic topical eye drops such as
apraclonidine and phenylephrine provide short temporary
lift of the upper eyelid in some patients. Use of topical
oxymetazoline hydrochloride (0.1%) for blepharoptosis
received FDA approval in July 2020

56. TAKE HOME MESAGE

57. 5 clinical measurement

58. PTOSIS
BY COURSE
Traumatic Mechanical Myogenic Aponeurotic Neurogenic
BY ONSET
CONGENITAL Acquired
Classification

59. Which operation is
prefered?
• Degree of ptosis is important
• Levator function is also important

60. Ptosis
Mild
Phrenylnephrine
test = positive
mullerectomy
Phrenylnephrine
test = negative
Fossanella
blepharoplasty
Levator
resection
moderate
Levator resection
Levator
advancement
severe Frontalis sling

61. THANK
YOU