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Ptosis
This document discusses ptosis, or drooping of the upper eyelid. It defines ptosis as the upper eyelid covering more than 2mm of the cornea. The document describes the different types of ptosis, including congenital, acquired, neurogenic, myogenic, aponeurotic, and mechanical. It also covers examinations for ptosis including measurements of marginal reflex distance, vertical fissure height, upper lid crease, and pretarsal show. The document discusses treatments for ptosis such as the Fasanella-Servat procedure, levator resection, and frontalis brow suspension.
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Ptosis
- 1. Dr. Christina Samuel PostgraduateOphthalmology MMCH & RI
- 2. OBJECTIVES DEFINITION TYPES EXAMINATION TREATMENT
- 3. DEFINITION Abnormal droopingof upper eyelids is called ptosis Normally upper eyelid covers 1/6th of cornea ie,. 2mm Therefore in ptosis it covers more than 2mm
- 4. TYPES OF PTOSIS 1.CONGENITAL PTOSIS #simple congenital ptosis #blepharophimosis syndrome #marcus gunn jaw winking ptosis(congenital synkinetic ptosis) 2.ACQUIRED PTOSIS #neurogenic ptosis #myogenic ptosis #aponeurotic ptosis #mechanical ptosis
- 5. CLASSIFICATION OF PTOSIS •Third nerve palsy 1. Neurogenic • Third nerve misdirection • Horner syndrome • Marcus Gunn jaw-winking syndrome • Myasthenia gravis • Myotonic dystrophy • Ocular myopathies • Simple congenital 2. Myogenic 3. Aponeurotic 4. Mechanical • Blepharophimosis syndrome
- 6. Simple congenital ptosis •Developmental dystrophy of levator muscle • Occasionally associated with weakness of superior rectus Unilateral or bilateral ptosis of varying severity In downgaze ptotic eyelid is slightly higher Frequent absence of upper lid crease Usually poor levator function
- 7. Blepharophimosis syndrome • Rarecongenital disorder • Dominant inheritance • Moderate to severe symmetrical pto • Short horizontal palpebral aperture • Telecanthus (lateral displacement of medial canthus) • Epicanthus inversus (lower lid fold larger than upper) • Lateral inferior ectropion • Poorly developed nasal bridge and hypoplasia of superior orbital rims
- 8. Marcus Gunn jaw-winkingsyndrome • Accounts for about 5% of all cases of congenital ptosis • Retraction or ‘wink’ of ptotic lid in conjunction with stimulation of ipsilateral pterygoid muscles Opening of mouth Contralateral movement of jaw
- 9. Left third nervepalsy Severe unilateral ptosis and defective adduction Normal abduction Defective elevation Defective depression
- 10. Bell’s phenomenon Upward rotationof globe on lid closure Good Poor - risk of postoperative corneal exposure
- 11. Right third nervemisdirection • Rare, unilateral • Aberrant regeneration following acquired third nerve palsy • Pupil is occasionally involved • Bizarre movements of upper lid accompany eye movements Right ptosis in primary position Worse on right gaze Normal on left gaze
- 12. Horner syndrome • Causedby oculosympathetic palsy • Usually unilateral mild ptosis and miosis • Slight elevation of lower lid • Normal pupillary reactions • Iris hypochromia if congenital or longstanding • Anhydrosis if lesion is below superior cervical ganglion
- 13. Important causes ofHorner syndrome Central (first order neurone) • Brainstem disease (vascular, demyelination) • Spinal cord disease (syringomyelia, tumours) Pre-ganglionic (second order neurone) • Intrathoracic lesions (Pancoast tumour, aneurysm) • Neck lesions (glands, trauma) Post-ganglionic (third order neurone) • Internal carotid artery disease • Cavernous sinus mass Posterior hypothalamus Ciliospinal centre of Budge( C8 - T2 ) Superior cervical ganglion
- 14. Myasthenia Gravis • Uncommon,typically affects young women 1 Clinical features. • Edrophonium (Camiston) test 2. Investigations • Medical - anticholinesterases, steroids and azathioprine 3. Treatment options • Weakness and fatiguability of voluntary musculature • Three types - ocular, bulbar and generalized • Antibodies to acetylcholine receptors • CT or MRI for presence of thymoma • Electromyography to confirm fatigue • Thymectomy
- 15. Ocular myasthenia • Insidious,bilateral but asymmetrical • Worse with fatigue and in upgaze Ptosis • Ptotic lid may show ‘twitch’ and ‘hop’ signs • Intermittent and usually vertical Diplopia
- 16. Myotonic dystrophy Facial weaknessand ptosis • Involvement of tongue and pharyngeal muscles • Ophthalmoplegia - uncommon • Muscle wasting • Hypogonadism • Frontal baldness in males • Intellectual deterioration • Presenile stellate cataracts Release of grip difficult
- 17. Ocular myopathies • Isolated •Oculopharyngeal dystrophy • Kearns-Sayre syndrome (pigmentary retinopathy) • Ptosis - slowly progressive and symmetrical • Ophthalmoplegia - slowly progressive and symmetrical (no diplopia) Clinical types Ocular features
- 18. Aponeurotic ptosis • Weaknessof levator aponeurosis • Causes - involutional, postoperative and blepharochalasis High upper lid crease Good levator function Absent upper lid crease Deep sulcus Mild Severe
- 19. Mechanical ptosis Causes Dermatochalasis Largetumours Severe lid oedema Anterior orbital lesions
- 20. Causes of pseudoptosis Ipsilateralhypotropia Brow ptosis - excessive eyebrow skin Dermatochalasis - excessive eyelid skin Lack of lid support Contralateral lid retraction
- 21. 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)
- 22. • Reflects levatorfunction • Normal (15 mm or more) • Good (12 mm or more) • Fair (5-11 mm) Upper lid excursion • Poor (4 mm or less)
- 23. • Distance betweenupper and lower lid margins • Normal upper lid margin rests about 2 mm below upper limbus • Normal lower lid margin rests 1 mm above lower limbus • Amount of unilateral ptosis is determined by comparison Vertical fissure height
- 24. Upper lid crease •Distance between lid margin and lid crease in down-gaze • Normals - females 10 mm; males 8 mm • Absence in congenital ptosis indicates poor levator function • High crease suggests an aponeurotic defect • Distance between lash line and skin fold in primary position of gaze Pretarsal show crease fold
- 25. Edrophonium test • Measureamount of ptosis or diplopia before injection • Inject i.v. atropine 0.3 mg • Inject i.v. test dose of edrophonium (0.2 ml-2 mg) • Inject remaining (0.8 ml-8 mg) if no hypersensitivity Before injection Positive result
- 26. Fasanella-Servat procedure Excision ofupper border of tarsus, lower border of Muller muscle and overlying conjunctiva Indicated for mild ptosis with good levator function ..
- 27. Levator resection Shortening oflevator complex Indicated for any ptosis provided levator function is at least 5 mm Amount determined by levator function and severity of ptosis
- 28. Frontalis brow suspension Attachmentof tarsus to frontalis muscle with sling Main indications • Severe ptosis with poor levator function ( 4 mm or less ) • Marcus Gunn jaw-winking syndrome
- 29.