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Ptosis.dr Ashfak.pptx
- 1. Ptosis & It’s Management Dr.Md.Ashfakur Rahaman(Rayhan) DO Student Dept.of Ophthalmology Rangpur Medical College
- 3. Normal lid Position • Upper lid covers 2 mm of cornea . • Lower lid touches the limbus
- 4. DEFINITION Abnormally low position of upper eyelids is called ptosis which may be Congenital or Acquired.
- 5. Classification Of Ptosis CONGENITAL PTOSIS • Simple congenital ptosis Congenital ptosis associated with • Blepharophimosis syndrome • Marcus gunn jaw winking phenomenon • 5. ACQUIRED PTOSIS • Neurogenic ptosis -Third nerve palsy -Third nerve misdirection -Horner syndrome • Myogenic ptosis -Myasthenia gravis -Myotonic dystrophy -Progressive external Ophthalmoplegia • Aponeurotic ptosis • Mechanical ptosis
- 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
- 8. Blepharophimosis syndrome • Moderate to severe symmetrical ptosis • 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
- 11. Marcus Gunn jaw-winking Phenomenon • Accounts for about 5% of all cases of congenital ptosis • Retraction or ‘wink’ of ptotic lid in conjunction with stimulation of ipsilateral pterygoid muscles
- 12. Grading of Marcus Gunn jaw-winking Phenomenon • Mild- maximum elevation of ptotic eyelid non- ptotic position • Moderate- maximum elevation goes upto superior limbus • Severe- maximum elevation beyond the superior limbus with scleral show
- 13. Retraction of lid on Opening of mouth
- 14. NEUROGENIC PTOSIS THIRD NERVE PALSY Congenital or acquired . - Eyeball is turned down, out slightly intorted due to actions of lateral rectus and superior oblique muscles. - Ocular movements restricted in all directions except outward. - Pupil is fixed and dilated due to paralysis of spinchter pupillae muscle. - Accommodation is completely lost due to paralysis of ciliary muscle
- 16. THIRD NERVE MISDIRECTION Rare, unilateral - Pupil is occasionally involved -Bizarre movements of upper lid accompany eye movements
- 17. HORNER SYNDROME: Characterized by classic triad of: • Mild ptosis • Miosis • Reduced ipsilateral sweating Other features include • mild enophthalmos • loss of cilio- spinal reflex • heterochromia • pupil is slow to dilate • slight elevation of the lower eyelid
- 19. Bell’s phenomenon • Upward rotation of globe on lid closure GRADING good= >2/3 of cornea disappears fair= 1/3 – 2/3 of cornea disappears poor= <1/3 of cornea disappears VARIANT - Inverse- upward & inward - Reverse- downward & outward - Preverse- different directions
- 20. Cont... • Corneal sensation- always check before planning the surgery. • Schirmers test – to rule out dry eye disease • Pupillary abnormalities - miosis in horner’s syndrome -mydriasis in 3rd nerve palsy
- 21. Phenylephrine test The function of muller’s is tested by applying drops of 10% phenylephrine to the eye on the side of blepharoptosis.
- 22. Myasthenia Gravis Clinical features • Uncommon, typically affects young women • Weakness and fatiguability of voluntary musculature • Three types - ocular, bulbar and generalized
- 23. Cogan‘s Lid Twitch Sign Characteristic of myasthenia • consists of a brief overshoot twitch of lid retraction following sudden return of the eyes to primary position after a period of downgaze
- 24. Investigations • Ice pack test • Edrophonium test • Antibodies to acetylcholine receptors • CT or MRI for presence of thymoma • Electromyography to confirm fatigue Other Test for Myasthenia • Generalized fatigue • Lid fatigue • Sleep test
- 25. ICE TEST • An ice pack is applied to the affected upper eyelid for 5 minutes. • A positive test is the improvement of ptosis by > 2mm or more.
- 26. Edrophonium (Tensilon)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
- 27. Treatment options Medical – anticholinesterases steroids and azathioprine Thymectomy
- 28. 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
- 30. Myotonic dystrophy • Facial weakness and ptosis • Involvement of tongue and pharyngeal muscles • Ophthalmoplegia - uncommon • Muscle wasting • Hypogonadism • Intellectual deterioration • Presenile cataracts • Release of grip difficult
- 31. Aponeurotic ptosis • Age related • Caused by dehiscence,disinsertion or stretching of levetor aponeurosis • Worsens towards the end of the day
- 33. Mechanical ptosis Large tumours • Caused by gravitational effect of mass Or by scarring.
- 34. Anterior orbital lesions Severe lid oedema
- 35. Causes of pseudoptosis • Lack of lid support • Contralateral lid retraction • Ipsilateral hypotropia • Brow ptosis • Dermatochalasis
- 36. Clinical Evaluation Of Ptosis When patient enters examination room, observation of the head posture with chin elevation and frontalis overaction indicate severe ptosis. Hand shake for exclude Myotonia
- 37. Clinical Cont.. HISTORY • Age of onset • Duration • Unilateral/bilateral • Weather ptosis worsen through the day • Diplopia • Muscle weakness • trauma/ surgery • lid edema • previous ptosis surgery
- 38. Cont.. • Presence of any aberrant lid movements • Weather eye movements are impaired • Past medical history • Current medications • Family history • Old photographs
- 39. EXAMINATION • Head posture • Vision • Periocular fullness • Frontalis overaction • Scar mark • Lid skin laxity • Telecanthus, epicanthus inversus
- 40. Ocular Motility: • Importance in myogenic ptosis, • To R 3rd nerve palsy • presence of strabismus, especially vertical strabismus entails that it be corrected prior to the correction of the ptosis. Visual acuity • Best-corrected visual acuity should be assessed to record any amblyopia if present, especially in cases of congenital ptosis
- 41. MEASUREMENTS Margin reflex distance • Margin reflex distance 1(MRD 1)- After shining the torchlight in the patient eye, the distance between the corneal light reflex to the centre of the upper lid margin is measured. • Normal value is 4- 4.5mm.
- 42. Margin reflex distance 2 (MRD 2)- the distance of corneal light reflex to the centre of the lower eyelid margin in primary gaze. Normal value is 5- 5.5mm
- 44. PALPABLE FISSURE HEIGHT • Distance between yhe upper lid margin and lower lid margin. Male 7-10mm Female 8-12mm
- 45. Levator function test • Levator function test- Excursion of upper eyelid from extreme downgaze to extreme upgaze is a measure of LPS function, negating the action of frontalis muscle (Berke’s method).
- 46. Cont... • Levator function is graded as follows: • Normal: 15mm or more • Good : 12-14mm • Fair : 5-11mm • Poor : 4mm or less
- 47. Upper lid crease • Vertical distance between lid margin and lid crease in downgaze • Male 8mm & Female 10mm • Absence of crease in Congenital ptosis • High crease in Aponeurotic ptosis Pretarsal show Distance between lid margin and the skin fold in Primary position.
- 48. Associated signs • The Pupil • Increased Innervation • Fatigability • Ocular motility defects • Jaw winking • Bell phenomenon • The tear film
- 49. Flow chart of Examination
- 50. Treatment A. Non surgical- Rehabilitative crutch glasses B. Surgical :Definitive treatment 1. Conjunctiva-Mullar resection ( Fasanella- Servat operation) 2. Levator advancement (resection) 3. Brow(frontalis) suspension
- 51. Conjunctiva-Mullar resection • Best results upto 2mm congenital ptosis with minimum 10mm levator action • 2mm tarsectomy performed for every 1mm ptosis • Used for mild neurogenic or myogenic ptosis
- 53. LEVATOR RESECTION • Skin Approach(Everbusch operation) • Conjunctival Approach • Indication:- Ptosis of any cause provided residual levetor function is at least 5mm.
- 55. Brow (Frontalis) suspension • Bilateral moderate to severe ptosis with poor levator action. • Indication:- Ptosis associated with third nerve palsy Blepharosphimosis Syndrome etc.
- 57. Complication • Undercorrection • Overcorrections • Eyelid crease abnormalities:- -Absence,Improper position • Logopthalmos • Exposure keratitis • Recurrence following surgery
- 58. Photographic documentation- it is the most important aspect of ptosis evaluation. Review of old photographs gives clue to the duration and nature of ptosis.
- 59. So we should examine case of ptosis carefully before proceeding for surgical management, to avoid any post operative surprise
- 60. Thank You