1) Ptosis is an abnormally low position of the upper eyelid that can be congenital or acquired. Congenital ptosis is usually bilateral and hereditary, caused by defective development of the levator palpebrae superioris muscle. Acquired ptosis has several causes including neurogenic (e.g. third nerve palsy), myogenic (e.g. myasthenia gravis), aponeurotic, or mechanical factors like tumors. 2) Myasthenia gravis is tested for using edrophonium, which temporarily improves ptosis and diplopia. Marcus Gunn jaw-winking syndrome is a rare form of congenital ptosis where the eyel

2. TYPES & CAUSES OF PTOSIS
by
Dr MAZHAR ALI

3. DEFINITION
• Ptosis is an abnormally low position of
the upper lid which may be congenital or
acquired

4. Typess
• Congenital
1. Simple
2. Complicated
• Acquired
1. Neurogenic
2. Myogenic
3. Aponeurotic
4 Mechanical
Pseudoptosis

5. Congenital Ptosis
• Commonest form of ptosis
• Usually bilateral / Heriditary
• Due to defective development of LPS
• Simple congenital ptosis is an isolated
abnormality

6. Congenital Ptosis
• Complicated – when associated with
developmental abnormality of surrounding
structures
Associated Superior rectus palsy
Abnormal synkineses – Marcus Gunn ptosis
Dystrophy of the LPS
Blepharophimosis syndrome (Ptosis,
horizontal shortening of palp aperture,
epicanthus inversus, telecanthus lat ectropion
of the lower lids)

7. 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

8. Marcus Gunn jaw-winking syndrome
• 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. Acquired Ptosis
• Usually unilateral
Types
1.Neurogenic – Third nerve paralysis or due to
reduced sympathetic innervation (Horner
syndrome – ptosis, anhydrosis and miosis)

10. Left third nerve palsy
Severe unilateral ptosis and
defective adduction Normal abduction
Defective elevation Defective depression

11. Horner syndrome
• Caused by 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

12. Right third nerve misdirection
• 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

13. Acquired Ptosis
2. Myogenic – gradual onset, bilateral
condition, symmetrical
Myotonic dystrophy
Chronic progressive exophthalmoplegia
Mysthenia gravis ( damage to acetyl-cholin
receptor at postsynaptic membrane with
presence of antiacetylcholine receptor
antibodies)

14. Acquired Ptosis
Mysthenia Gravis-
Symptoms – variable
Signs – bilateral ptosis, increases by
prolonged fixation or attempt to look up ,
external ophthalmoplegia – partial or
complete
Conformation by edrophonium injection
test

15. Ocular myasthenia
• Insidious, bilateral but asymmetrical
• Worse with fatigue and in upgaze
Ptosis
• Intermittent and usually vertical
Diplopia

16. Edrophonium test
• Measure amount 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

17. Acquired Ptosis
Aponeurotic Ptosis
Is involutional is due to weakness
or disinsertion of LPS aponeurosis from ant
surface of tarsal plate
High lid fold with good LPS function

18. Aponeurotic ptosis
• Weakness of levator aponeurosis
• Causes - involutional, postoperative and blepharochalasis
High upper lid crease Good levator function
Absent upper lid crease Deep sulcus
Mild
Severe

19. Acquired Ptosis
• Mechanical Ptosis –
• ptosis is caused by the gravitational effect
of a mass or by scarring
• Tumour or inflammation weight down the
lid

20. Mechanical ptosis
Causes
Dermatochalasis Large tumours
Severe lid oedema Anterior orbital lesions

21. Pseudoptosis
• 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
• 2 Contralateral lid retraction,
•
3 Ipsilateral hypotropia causes pseudoptosis because
the upper lid follows the globe downwards
• 4 Brow ptosis due to excessive skin on the brow, or 7th
nerve palsy,

22. Causes of pseudoptosis
Ipsilateral hypotropia Brow ptosis - excessive
eyebrow skin
Dermatochalasis - excessive
eyelid skin
Lack of lid support Contralateral lid retraction

23. THANKS