The document discusses levator palpebrae superioris muscle, the main elevator of the upper eyelid, and ptosis (drooping of the upper eyelid). It describes the different types of ptosis including congenital and acquired forms. Evaluation of ptosis involves measuring the margin reflex distance, levator function, palpebral fissure size, eyelid crease position, and presence of lagophthalmos. Surgical correction of congenital ptosis aims to avoid amblyopia and involves levator advancement, resection, or frontalis sling procedures. Complications can include under or overcorrection and eyelid asymmetry.

2.  Levator plapebre superioris LPS
 Origin: lesser wing of sphenoid bone
 Insertion: tarsus ,medial and lateral canthal tendon
 Function: 50-55 mm long. Elevate UEL by 15 mm
 Innervation: superior division of CN III
 Frontalis , accessory elevator of upper eyelid
 Elevated UEL by 2 mm , supplied by CN VII

4.  Ptosis is Greek word
means “fall”
 Blepharoptosis ; Is
described as drooping
of upper eyelid, the
shortened form
,ptosis, is frequently
used in place.

5. Congenital
Acquired:
1. myogenic
2. aponeurotic
3. neurogenic
4. mechanical
PESUDOPTOSIS

6.  Is the most common type
 Which results from dysgenesis of levator muscle
 Instead of normal muscle fibers , fibrous or adipose
tissue is present in muscle belly
 Therefore congenital ptosis resulting from levator
maldevelopment characterized by decreased levator
function, eyelid lag and sometimes lagophthalmos.
 Congenital myogenic ptosis associated with poor Bell
phenomenon or with vertical strabismus may indicated
concomitant superior rectus maldevelopment (double
elevator palsy or monocular elevation deficiency)

8.  Is rare type of congenital ptosis
 Caused by innervational defect that occur during
embryonic development.
 This condition is commonly associated with
congenital Third cranial nerve palsy, congenital
Horner syndrome or Marcus Gunn jaw-winking
syndrome.

10. Evaluation

11.  Ptosis
 Age of onset (congenital ,
acquired)
 Duration
 One or both eyes
 Diurnal difference
 Associated symptoms
o Dysphagia
o Diplopia
o Muscle weakness
 Vision
 Associated with
o Jaw movement
o Abnormal ocular movements
o Abnormal head posture
 History of trauma
 Family history
 Previous photo may
help

12.  Physical examination by 5 clinical measurements
1. Margin-Reflex Distance (MRD)
2. Levator function (upper eyelid excursion)
3. Vertical palpebral fissure
4. Upper eyelid fold (crease postion)
5. Presence of lagophthalmos
 Severity of ptosis can be measured by these
findings

13.  MRD is distance from
upper eyelid margin to the
corneal light reflex in
primary position of gaze.
 Is probably single most
important measurement in
describing amount of
ptosis.
 Normally 4-5 mm
 If Margin above reflex
value is +ve
 But if margin is below
reflex is of –ve value

14.  Is measured at widest
point between upper
and lower eyelid
 The measurement is
taken while patient is
fixating on a distance
object on primary
gaze

15.  The distance from UEC to the eyelid margin is measured
 Insertion of fibers from levator muscle into skin
contribute to the formation of UEC.
 Asymmetric crease may indicate an abnormal position of
levator aponeurosis
 UEC is 8-9 mm in males and 9-11 mm in females , this is
in Caucasians , while UEC is lower or obscured in the
Asian eyelid with or without ptosis.
 Crease is usually elevated in involutional ptosis, and is
often shallow or absent in congenital ptosis

16. Is estimated by
measuring upper
eyelid excursion ,
from downgaze to
upgaze with
frontalis muscle
function is negated
by digital pressure
on brow.

17. Finally the patient should be assessed for
lagophthalmos.

18.  Other findings include head position , chin elevation ,
brow position and brow action in attempted upgaze
 Assessment of VA and refraction as amblyopia occur
in 20%.
 Assessment of EOMs
 Variation in amount of ptosis with jaw muscle and
EOMs movements.
 Pupillary examination is important in evaluation of
ptosis
 External examination of other abnormalities like
telecanthus, epicanthus inversus ,flattening of superior
orbital rim, horizontal shortening of eyelid and
hypoplais of nasal bidge all these indicated (congenital
blepharophimosis syndrome)

21.  Repair of congenital ptosis is when there is compensatory chin
up position or severe ptosis to avoid occlusion amblyopia.
Otherwise it can be delayed till child become several years
old.
 External (transcutaneous) levator advancement
 Internal (transconjunctival) levatortarsusmullar muscle
resection
 Frontalis muscle suspension (when levator function is less
than 4 mm.
- transcutaneous
- transconjunctiva
 Autogenous fascia lata is used for frontalis suspension when
child is 3-4 years
 Recurrence rate is 50% after 8 – 10 years.

24. 1. Undercorrection
2. Overcorrection
3. Asymmetric eyelid contour
4. Scarring
5. Wound dehiscence
6. Conjunctival prolapse
7. Eyelid crease asymmetry
8. Tarsal eversion
9. Lagophthalmos with exposure keratitis