This document summarizes different types and causes of ptosis presented by Nazneen Nasir. It discusses acquired ptosis which can be neurogenic, myogenic, aponeurotic, or mechanical. Congenital ptosis and pseudo ptosis are also mentioned. Examination techniques for ptosis including margin-reflex distance, palpebral fissure height, and levator function are outlined. Surgical correction methods such as Müllerectomy, levator resection, and brow suspension are briefly described for different types and severities of ptosis.

1. PRESENTATION BY NAZNEEN NASIR
FORTH YEAR MBBS

2.  Ptosis is an abnormally low position of the
upper lid
 it may be congenital or acquired

3.  ACQUIRED:
1) Neurogenic ptosis
2) Myogenic ptosis
3) Apo neurotic or involutional ptosis
4) Mechanical ptosis
 Pseudo ptosis
 CONGENITAL PTOSIS

8.  myopathy of the levator muscle itself,
 or by impairment of transmission of impulses
at the neuromuscular junction
(neuromyopathic).
 Acquired myogenic ptosis occurs in
:myasthenia gravis, myotonic dystrophy and
progressive external ophthalmoplegia

10.  Aponeurotic or involutional ptosis is caused
by a defect in the levator aponeurosis

11.  Mechanical ptosis is caused by the
gravitational effect of a mass or by scarring

12.  A false impression of ptosis
 • Lack of support of the lids by the globe may be due to an
orbital volume deficit associated with an artificial eye,
microphthalmos, phthisis bulbi or enophthalmos.
 • Contralateral lid retraction, which is detected by comparing the
levels of the upper lids, remembering that the margin of the
upper lid normally covers the superior 2 mm of the cornea
• Ipsilateral hypotropia causes pseudoptosis because the upper lid
follows the globe downwards It disappears when the hypotropic
eye assumes fixation on covering the normal eye.
 • Brow ptosis due to excessive skin on the brow, or seventh
nerve palsy, which is diagnosed by manually elevating the
eyebrow
 • Dermatochalasis. Overhanging skin on the upper lids may be
mistaken for ptosis, but may also cause mechanical ptosis.

14.  The age at onset of ptosis and its duration will usually
distinguish congenital from acquired cases.
 If the history is ambiguous, old photographs may be helpful.
 It is also important to enquire about symptoms of possible
underlying systemic disease, such as associated;
 Diplopia
 variability of ptosis during the day
 excessive fatigue

15.  Margin–reflex distance
 Palpebral fissure height
 Levator function (upper lid excursion)
 Upper lid crease
 Pretarsal show

16.  Margin–reflex distance is the distance between the upper lid
margin and the corneal reflection of a pen torch held by the
examiner on which the patient fixates
 the normal measurement is 4–5 mm.

17.  distance between the upper and lower lid margins, measured
in the pupillary plan
 The upper lid margin normally rests about 2 mm below the
upper limbus and the lower 1 mm above the lower limbus.
 This measurement is shorter in males (7–10 mm) than in
females (8–12 mm)
 Ptosis may be graded as mild (up to 2 mm), moderate (3 mm)
and severe (4 mm or more).

18.  measured by placing a thumb firmly against the patient’s
brow to negate the action of the frontalis muscle, with the
eyes in downgaze.
 The patient then looks up as far as possible and the amount
of excursion is measured with a rule
 Levator function is graded as normal (15 mm or more), good
(12–14 mm), fair (5–11 mm) and poor (4 mm or less).

20.  distance between the lid margin and the skin
fold with the eyes in the primary position.

21.  The pupils: examined to exclude Horner syndrome
and a subtle pupil-involving third nerve palsy
 Increased innervation may flow to the levator
muscle of a unilateral ptosis, particularly in
upgaze.
 Fatigability is tested by asking the patient to look
up without blinking for 30–60 seconds
 Ocular motility defects, particularly of the superior
rectus, must be evaluated in patients with
congenital ptosis.

22.  Jaw-winking can be identified by asking the
patient to chew and move the jaws from side
to side

23.  tested by manually holding the lids open, asking the patient
to try to shut the eyes and observing upward and outward
rotation of the globe. A weak Bell phenomenon carries a
variable risk of postoperative exposure keratopathy,
particularly following large levator resections or suspension
procedures

24.  should be inspected – a poor volume or unstable film may be
worsened by ptosis surgery and should be addressed
preoperatively as far as possible.

25.  About 5% of all cases of congenital ptosis are
associated with the Marcus Gunn jaw-winking
phenomenon.
 majority are unilateral.
 a branch of the mandibular division of the
fifth cranial nerve is misdirected to the
levator muscle.

26.  Retraction of the ptotic lid in conjunction with
stimulation of the ipsilateral pterygoid
muscles by chewing, sucking, opening the
mouth
 contralateral jaw movement.
 Less common stimuli to winking include jaw
protrusion, smiling, swallowing and clenching
of teeth.
 Jaw-winking does not improve with age
although patients may learn to mask it.

27.  Surgery should be considered if jaw-winking or
ptosis represents a significant functional or cosmetic
problem.
• Mild cases with reasonable levator function of 5 mm
or better, and little synkinetic movement may be
treated with unilateral levator advancement
• Moderate cases. Unilateral levator disinsertion can be
performed to address the synkinetic winking
component, with ipsilateral brow (frontalis)
suspension so that lid elevation is due solely to
frontalis muscle elevation.
• Bilateral surgery. Bilateral levator disinsertion with
bilateral brow suspension may be carried out to
produce a symmetrical result.

28.  Mechanical ptosis is the result of impaired
mobility of the upper lid. It may be caused by
dermatochalasis, large tumours such as
neurofibromas ,heavy scar tissue, severe
oedema and anterior orbital lesion.

29.  This involves excision of Müller muscle and overlying
conjunctiva with reattachment of the resected edges
 The maximal elevation achievable is 2–3 mm, so it is used in
cases of mild ptosis with good (at least 10 mm) levator
function, which includes most cases of Horner syndrome and
mild congenital ptosis.

30.  In this technique the levator complex is shortened through
either an anterior – skin– or posterior – conjunctival –
approach. Indications include ptosis of any cause, provided
residual levator function is at least 5 mm.
 The extent of resection is determined by the severity of the
ptosis and the amount of levator function.

31.  Brow (frontalis) suspension is used for severe
ptosis (>4 mm) with very poor levator
function