Ptosis, or drooping of the upper eyelid, can have several causes including paralysis or disease (myogenic, neurogenic), or be congenital (aponeurotic). Myogenic ptosis may be congenital due to poor levator muscle contraction/relaxation, or acquired like in myasthenia gravis where the myoneural junction is defective. Neurogenic ptosis includes third nerve palsy or Horner's syndrome. Aponeurotic ptosis includes senile or postoperative changes. Treatment depends on the cause and degree of ptosis, and may involve frontal sling surgery using the frontalis muscle, levator resection/advancement for moderate ptosis, or Whitnall sling or

1. Ptosis
By
Dr. Amr Mounir
Lecturer of Ophthalmology
Sohag University

2. Definition:
It is drooping of the upper eyelid due to paralysis or
disease, or due to a congenital condition.

3. Etiology

Myogenic

Neurogenic

Aponeurotic

Mechanical

4. Myogenic ptosis
A)Congenital ptosis: due to dystrophy of levator
muscle lead to poor contraction and incomplete
relaxation

5. B) Acquired ptosis
(Myasthenia gravis) : due
to defect in the myoneural
junction.. it is progressive
the end of the day and on
prolonged fixation

6. Neurogenic ptosis
Third nerve palsy : paralytic ptosis
(Diabetes- congenital-traumatic)
Horner’s syndrome : due to interference
with sympathetic nerve supply with
characteristic ptosis, miosis, anhidrosis and
enophthalmos

7. Aponeurotic ptosis
(disorder in levator
aponeurosis)

Senile (involutional): degenerative
changes with age

Postoperative ptosis:
following cataract surgery and retinal
detachment surgery (damage of
levator ,superior rectus comlex)

8. Mechanical ptosis
Excess eyelid weight
(edema-tumor-
chalizion)

9. Degree of ptosis
1- Assessment of ptosis:
Degree of ptosis
(Margin-reflex-distance):normal (4-4.5mm)
Mild 2mm dropping
Moderate 3mm dropping
Severe 4-4.5mm dropping

10. 2- Levator function tests:
1-Distance of U.L :
movement from down gaze to up
gaze(upper lid excursion)
2-Upper lid crease presence
15 mm Normal 5-11mm Fair
12-15mm Good 5mm Poor

11. 3)Associated signs:
Marcus-Gunn (jaw-winking) phenomenon:
Ocular motility
Bell’s phenomenon
Corneal sensation
Squint
Increased innervation
Pupil: ptosis &mydriasis>>third nerve palsy
Ptosis &miosis>> horner’s syndrome

12. Marcus-Gunn (jaw – winking) phenomenon

13. Bell’s phenomenon

14. Corneal sensations

15. The Effect of Hering's Law in Ptosis
with increased innervation

16. Pupil Appearance
3rd nerve Palsy Horners Synrome

17. Differential diagnosis
Causes of pseudo-ptosis
Contralateral side Ipsilateral side
•
Lid retraction
•
Severe proptosis
•
Lack of support
•
Hypotropia
•
Excessive
dermatochalesis

18. Treatment
Aim of surgery:
1) Maintenance of correct eyelid position
2) Preservation of the normal eyelid crease
3) Maintenance of the normal tear film
4) Prevention of exposure keratopathy by
prevention of over correction.

19. Frontalis sling
Involves creation of a linkage
between the frontalis muscle and
the tarsal and epitarsal tissue of the
upper eyelid.
This allows eyelid elevation to be
performed through the use of the
frontalis muscle, thereby bypassing
a poorly functioning levator.

20. Indicated in congenital ptosis and
poor levator function or congenital
Marcus Gunn jaw wink phenomenon.
Disadvantages of this procedure
include the risk of lagophthalmos and
eyelid lag in down gaze, scarring in
young children, loss of the eyelid
crease, and The recurrence rate of
ptosis after 20 months
postoperatively is 26%

21. Levator resection and
advancement
Patients with greater than 5 mm of
levator function.
Advantages: it preserves normal
anatomical planes and structures
of the eyelid.

22. WHITNALL SLING
Indicated in severe ptosis with
levator function of 3–5 mm.
This procedure involves
resecting the levator
aponeurosis up to the point of
Whitnall's ligament, and then
suturing both Whitnall's
ligament and the underlying
levator muscle to the superior
portion of the tarsal plate.

23. MULLERECTOMY
The Muller's muscle is an
involuntary, sympathetically
innervated muscle that
originates below the levator
aponeurosis.
It is indicated for patients
who respond well to the
phenylephrine test, thereby
shortening Muller's muscle.

24. Thank You