The document discusses ptosis, a condition characterized by the drooping of the upper eyelid, detailing its definition, classifications, clinical features, diagnostic methods, and treatment options. It includes congenital types, neurogenic and myogenic forms, and management strategies ranging from non-surgical interventions to various surgical techniques. Diagnosis relies on a thorough assessment of eyelid position, muscle function, and associated ocular anomalies.

1. By Dr. Sulaiman
Oral And
Maxillofacial Surgery

2. Definition
Functional anatomy
Classification
Managment

3. Ptosis (from Greek Ptosis -to "fall") is drooping or falling
of the upper eyelid below its normal position. "lazy eye"

4. Levator Palpebrae Superioris
Primary muscle for lid elevation.
Supplied by the superior division of the oculomotor nerve.
Arises from the back of the orbit and extends forwards over the
cone of eye muscles.
Inserts into the eyelid and the tarsal plate, a fibrous semicircular
structure which gives the upper eyelid its shape.

7. Ptosis
Congenital
Simple
congenital
With abnormal
movements
With lid
abnormalities
Acquired
Myogenic Neurogenic Aponeurotic Mechanical
Pseudoptosis

8. 1. Simple congenital ptosis
 not associated with any other anomaly.
2. Congenital ptosis with associated weakness of
superior rectus muscle.

9. 3.Blephrophimosis
◦ which comprises congenital
ptosis, blepharophimosis,
telecanthus and epicanthus
inversus .

10. Clincal Features
 Dominent inheritance
 Moderate to severe symmetrical ptosis
 Short horizontal palpebral aperture
 Telecanthus (lateral displacement of medial canthus)
 Epicanthus inversus (lower lid fold larger than upper)
 Poorly developed nasal bridge
and hypoplasia of superior orbital
rims

11. 4. Congenital synkinetic ptosis
(Marcus Gunn jaw winking ptosis).
In this condition there occurs retraction of the
ptotic lid with jaw movements i.e., with
stimulation of ipsilateral pterygoid muscle.

12.  Usually unilateral
Types :
1. Neurogenic
 Third nerve paralysis
 Due to reduced sympathetic innervation (Horner
syndrome – ptosis, anhydrosis and miosis)

13. C…Defective elevation D…Defective depression
B. Normal abductionA. Severe unilateral ptosis and
defective adduction

15. – gradual onset, bilateral
condition, symmetrical
1. Myotonic dystrophy
2. Chronic progressive
exophthalmoplegia

16. 3. Mysthenia Gravis
Signs – bilateral ptosis, increases by prolonged
fixation or attempt to look up , external
ophthalmoplegia – partial or complete
Conformation by edrophonium injection test

17. 1. Post Operative ptosis due to disinsertion of
Levator Palpebrae Superioris aponeurosis
from ant surface of tarsal plate.
2. Posttraumatic Dehiscence or Disinsertion
3. Involutional (snile) ptosis due to weakness.
Clincal sign
High fold with good Levator palpebrae superioris
function.

18. High upper lid crease Good levator function
Deep sulcusAbsent upper lid crease
Mild
Severe

19. Ptosis is caused by the gravitational effect
of a mass or by scarring
Tumour or inflammation weight down the lid

20. Dermatochalasis Large tumours
Anterior orbital lesionsSevere lid oedema

21. 5. Snake Venom
(Black Mumba)
6. Drugs
1. Opioid
(morphine, oxycodone,
heroin)
2. anticonvulsant
(Pregabalin)

22. False impression of ptosis may be caused
by the following
1. Lack of support of the lids by the globe
may be due to an orbital volume deficit
associated with an artificial eye

27. 1. Diagnosis is based on
 history
 examination,
 eye measurements,
 clinical and laboratory tests and
 imaging studies
2. Treatment

28. 1. Age of onset
2. Duration
3. One/both eye
4. Associated history
5. Diplopia
6. Dysphagia
7. Muscle weakness
8. Vision
9. Jaw movements
10.Abnormal ocular
movements
11.Abnormal head
posture
12.Previous history
13.Trauma
14.Poisoning
15.Bleeding tendency
16.Previous photographs
17.Family history

29.  NORMAL POSITION OF EYELID
Usually 1-2mm below the limbus
 Vertical Palpebral fissures are normally 9-12mm.
Check for
1. Unilateral or bilateral , Complete or incomplete
2. Ocular motility
3. Visual acuity
4. Pupillary examination
5. Chin elevation

30. 1.Vertical fissure height
2.Margin reflex distance
3.Levator palpebrae Superioris action
4.Lid crease level
5.Lid level on down gaze

31.  Normal – 9-
10mm in
primary gaze
 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

34. MRD 2
 The distance from the central pupillary light reflex to the lower
eyelid margin with the eye in primary gaze.
 The MRD1 plus the MRD2 should equal the palpebral fissure
measurement

35. Lid excursion is a measure of the levator function. The
frontalis action is blocked by keeping the thumb tightly
over the upper brow and asking the patient to look up
from down gaze and measuring the amount of upper
lid excursion at the center of the lid.

37.  Is the distance from the
crease to lid margin
 Normal – 8 to 10mm in
primary gaze
 An absent lid crease is often
accompanied by poor levator
function.
 If a lid crease is present but
is higher than normal and if
a deeper upper lid sulcus is
found on that side, note
these as signs of a levator
aponeurosis disinsertion.

38. Patients with Minimal
ptosis (2 mm or less)
 2.5 or 10% phenylephrine
is instilled in the affected
eye or eyes
The patient is reexamined 5
minutes later.
 The MRD1 is rechecked in
the affected and unaffected
eyes .
 A rise in the MRDl of 1.5
mm or greater is
considered a positive
test. This indicates that
Müller's muscle is viable

39. Non Surgical
Surgical
Herrings Law
Muscles that elevate the eyelids get the same
innervation
 The lid with minimal ptosis droops more following
the correction of greater ptotic side
 Important for prediction of post op results

40. A.Non Surgical
1.Lid crutches

41. 2. Haptic contact lens

42. 3. lid elevation by mechanical force

43. Surgical management depends upon the type of ptosis
and levator function
Indications
 Complete ptosis
 Chin up positioning
 Severe ptosis causing amblyopia
Contraindications
 Poor orbicularis muscle function
 Loss of blink reflex
 Corneal sensitivity
 Keratitis sicca

45. Mild ptosis
Phenylephrine +ve
Mullerectomy
Phenylephrine - ve
Fasanella servat
Blepharoplasty
Levator resection

50. Ptosis
Moderate
Levator resection Levator
advancement
Severe
Frontalis sling

55. 1. Asymmetry

56. 2. Corneal abrasion or Keratitis

57. 3. Entropion or Ectropion

58. 4. Eyelashes loss

59. 5. Wound Dehiscence

60. 6. Unfavorable scar