you will get knowledge about the ptosis, its different types, its examination, its measurement, its treatment in detail. different eyelid muscles such as LPS, Orbicularis oculi and frontalis are also explained.

2. Ptosis
BY
ANAM
SEHREEN
DOCTOR OF
OPTOMETRY

3. PTOSIS
Ptosis is an abnormally low
position of the upper lid.
Grading and severity
Normally upper eyelid cover 1/6th of cornea
 Mild < or = 2mm
 Moderate = 3mm
 Severe > 4mm

4. FUNCTIONAL ANATOMY
Levator Palpebral Superioris (LPS):
 Is the primary muscle responsible for lid elevation.
 It arises from the back of the orbit and extends forwards
over the cone of eye muscles.
 It inserts into the eyelid and the tarsal plate, a fibrous
semicircular structure which gives the upper eyelid its
shape.
 The LPS is supplied by the superior division of the
oculomotor nerve.

5. Muller’s Muscle:
 The way that the LPS attaches to the tarsal plate is
modified by the underlying Müller's muscle.
 This involuntary muscle, comprising sympathetically
innervated smooth muscle
 Has the capacity to 'tighten' the attachment and so raise
the lid a few millimetres.
Frontalis and Orbicularis Oculi muscles:
 Both muscles supplied by the facial nerve.
 Frontalis contraction helps to elevate the lid by acting
indirectly on the surrounding soft tissues, while orbicularis
oculi contraction depresses the eyelid.

6. CLASSIFICATION
It may be
 Acquired
 Congenital
Acquired
1) Neurogenic
2) Myogenic
3) Aponeurotic
4) Mechanical
5) Neurotoxic

7. 1). NEUROGENIC
It caused by an innervational defect such as 3rd nerve
paresis and Horner's Syndrome.
 3rd nerve misdirection syndrome
• Rare, unilateral
• Aberrant regeneration following acquired 3rd nerve palsy
• Bizarre movements of upper lid accompany eye
movements
• Pupil is occasionally involved
• Right ptosis primary position
• Worse on right gaze
• Normal on left gaze

8.  HORNER SYNDROME:
It is a relatively rare disorder characterized by:
 A constricted pupil (miosis)
 Drooping of the upper eyelid (ptosis)
 Absence of sweating of the face (anhidrosis)
 Sinking of the eyeball into the bony cavity that protects
the eye (enophthalmos)

9. 2). MAYOGENIC:
 Caused by the myopathy of the levator muscle itself or
by the impairment of the transmission of impulses at the
neuro muscular junction
 Acquired myogenic occurs in myasthenia gravis
myotonic dystrophy and progressive external
ophthalmoplegia.

10. 3). APONEURATIC
Caused by a defect in
the levator aponeurosis
Involutional ptosis
Aponeuratic ptosis also called senile or involutional ptosis, is the
most common type of acquired ptosis. It is caused by a disinsertion
or dehiscence of the levator aponeurosis from the tarsus.
 Clinical exam reveals a high lid crease, generally good levator
function and typically worsening of the ptosis on downgaze.
 Such patients tend to do well with surgical correction which
involves advancement and reattachment of the levator
aponeurosis to the anterior tarsal surface.

11. 4). MECHANICAL:
With mechanical ptosis, the eyelid is weighed down by
excessive skin or a mass.
 Traumatic ptosis is caused by an injury to the eyelid.
Either due to an accident or other eye trauma.
 This injury compromises or weakens the levator muscle

12. CONGENITAL
1) Simple congenital ptosis
2) Congenital ptosis
3) Congenital synkinetic ptosis
4) Blepharophimosis Syndrome
1). Simple congenital ptosis
Not associated with any anomaly

13. 2). Congenital ptosis
 It results from a failure of neuronal migration or development with
muscular sequalae.
 Superior Rectus weakness
 Compensatory Chin elevation
 Absent upper lid crease
 In downward gaze the ptotic lid is higher then the normal because
of poor relaxation of the levator function
3). Congenital Synkinetic ptosis
 Marcus Gun Jaw winking Ptosis

14. MARCUS GUN JAW WINKING PTOSIS
About 5% of the congenital cases are associated with the Marcus
gun jaw winking phenomenon.
 Retraction of the ptotic lid in conjunction with stimulation of the
ipsilateral
 Pterygoid muscle by chewing, sucking, opening the mouth
 Less common stimuli to winking include jaw protrusion, smiling,
swallowing and clenching of teeth
 Jaw winking does not improve with age
 Exact aetiology is unclear

15. PSEUDOPTOSIS
False impression of the ptosis which may be caused by:
 LACK OF SUPPORT
 Lack of support of the lids by the globe ma be due to the orbital
volume deficient associated with enophthalmos.
 CONTRALATERAL LID RETRACTION
 Which is detected by comparing the levels of upper eyelids the
margin of the upper lid mat cover the superior 2mm of cornea
 IPSILATERAL HYPOTROPIA
 Upper lid follows the globe downward
 BROW PTOSIS
• Due to excessive skin on the brow

17. SIGN AND SYMPTOMS OF PTOSIS
 Dropping eyelid
 Raising of the eyebrows to lift the eyelids for better
vision
 Watery eye
 Tilting the head
 Aching in and around the eyes
 Looking tired
 Double vision
 Difficulty closing the eyes or blinking

18. EVALUATION OF PTOSIS:
 History:
 Age of onset
 Duration
 One/both eye
 Diurnal variability
 Associated history:
o Diplopia
o Dysphagia
o Muscle weakness
 Vision

19.  Associated with:
 Jaw movements
 Abnormal ocular movements
 Abnormal head posture
 History of:
 Trauma or previous surgery
 Poisoning
 Use of steroid drops
 Any reaction with anesthesia
 Bleeding tendency
 Previous photographs may prove to be of great help.
 Is there a family history of ptosis or of other muscle
weakness?

20. OCULAR EXAMINATION
Normal position of eyelids:
 The normal upper eyelid in primary position
 Crosses the iris b/w the limbus (junction of the iris and sclera)
and the pupil
 Usually 1 mm to 2 mm below the limbus
 The lower lid touches or crosses slightly above the limbus.
 Normally there is no sclera showing above the iris.
Palpebral fissures:
It is normally 9 mm to 12 mm from upper to lower lid margin
Visual Acuity:
Best-corrected visual acuity should be assessed to record any
amblyopia if present, especially in cases of congenital ptosis.

21. PUPILLARY EXAMINATION
 TO diagnosis Horner’s syndrome
 Involvement in a case of third nerve palsy
 TOTAL UNILATERAL PTOSIS
 Complete third nerve palsy.
 MILD TO MODERATE PTOSIS
 Horner's syndrome
 partial third nerve palsy.
 MILD TO MODERATE BILATERAL PTOSIS
 Neuromuscular disorders such as MG
 Muscular dystrophy
 Ocular myopathy

22. MEASUREMENTS
1) Margin reflex distance
2) Vertical fissure height
3) LPS action
4) Lid crease level
5) Lid level on down gaze

23. 1). MARGIN REFLEX DISTANCE:
Margin-to-reflex distance 1 (MRD1)
• When light is thrown on the cornea, a reflection
occurs.
• The distance from the central pupillary light reflex to
the upper eyelid margin with the eye in primary gaze.
• If the margin is above the light reflex the MRD 1 is a
+ve value.
• If the lid margin is below the corneal reflex in cases of
very severe ptosis the MRD 1 would be a –ve value.

25. 2). VERTICAL FISSURE HEIGHT
 The distance between the upper and lower eyelid in vertical
alignment with the center of the pupil in primary gaze, with the
patient’s brow relaxed.
Normal – 9-10mm in primary gaze
 Should be seen in up gaze, down gaze and primary gaze
 Amount of ptosis = difference in palpebral apertures in unilateral
ptosis or Difference from normal in bilateral ptosis

26. 3). LEVATOR FUNCTION ASSESSMENT
 It is determined by the lid excursion caused by LPS muscle
(Burke’s method).
 Patient is asked to look down and thumb of one hand is placed
firmly against the eyebrow of the patient (to block the action of
frontalis muscle) by the examiner.
 Then the patient is asked to look up and the amount of upper lid
excursion is measured with a ruler held in the other hand by the
examiner.
 Levator function is graded as follows:
 Normal 15 mm
 Good 8 mm or more
 Fair 5-7 mm
 Poor 4 mm or less

27. INVESTIGATION
 Serum acetylcholine receptor assay
 Tensilon test
 EMG
 ECG
 ERG
 T3, T4, TSH

28. TREATMENT
CONGENITAL PTOSIS
Almost always surgical treatment
AQUIRED PTOSIS
 Treat the underlying cause
 Surgey
 Fasanella servant operation
 Levator resection
 Frontalis sling operation

31. FASANELLA-SERVAT PROCEDURE
 Indicated for mild ptosis(1.5-2mm) with good levator
function

32. LEVATOR RESECTION
 Indicated for any ptosis provided levator function is at least 5mm.
 Contraindicated in patients having severe ptosis with poor
levator function.

33. FRONTALIS BROW SUSPENSION
 Used in severe ptosis with poor levator function (4 mm or less).
 The tarsal plate is suspended from the frontalis muscle with a
sling consisting of autologous fascia lata or non absorbable
material such as prolene or silicon.
 Marcus Gunn jaw-winking syndrome