all about ptosis and its evaluation

2. PRESENTATION LAYOUT
INTRODUCTION
TYPES OF PTOSIS
 EVALUATION OF PTOSIS
CASE STUDY
REFERENCES

3. Introduction
Blepharoptosis, abbrev. Ptosis (pronounced as “toe-sis)
Ancient Greek:
-Blepharon: Eye lid
-Ptosis: Falling
Blepharoptosis means drooping or falling of upper eyelid.

4. Eyelid: Brief Introduction
Mobile tissue acts as shutter protecting the eye
Lid folds
-Superior lid fold (4mm above the edge of Upper lid)
-Inferior lid fold
-Nasojugal fold
-Malar fold

5. Eyelid: Dimensions
Lid position
-In primary position upper lid covers 1/6th (2mm) of cornea and
lower lid just touches the cornea
Palpebral aperture
-Elliptical space
-18-21mm (H) and 8mm (V) at birth
-28-30mm (H) and 9-11mm (V) adult

6. Muscles for Eyelid Movement
LPS:
-Primary elevator
-Elevates eye upto 15mm
-Supplied by 3rd CN
-LPS of 2 eyes receives equal innervations (Hering’s law)
 Frontalis muscle:
-Accessory elevator
-Helps in 3-5mm additional elevation beyond LPS action
-Temporal branch of facial nerve

7. Muscles for Eyelid Movement
Muller’s muscle
-Part of LPS (non striated)
-Receives sympathetic supply
-Long term adjustment of eyelid position
-Can elevate eyelid upto 1-4mm
Orbicularis Oculi
-Eyelid closing
-Supplied by facial nerve
-Has reciprocal relation with LPS ( Sherrington’s law)

8. Why need to know Ptosis?
Ptosis is relatively common yet often overlooked and under
reported
Has cosmetic concern
Has significant ocular and non ocular morbidity
-Browache, Headache, Heavy eyes
-Loss of superior visual field
-Forehead furrows, tired appearance
-Psycho Social impact

9. Ptosis Classification
Congenital Ptosis
Simple congenital Ptosis
Blepharophimosis
syndrome
With superior rectus muscle
weakness
Marcus Gunn Jaw winking
syndrome
Acquired Ptosis
Aponeurotic
Ptosis
Myogenic Ptosis
Neurogenic Ptosis
Mechanical Ptosis

10. Simple Congenital Ptosis
Present at birth or soon after birth
Pathogenesis: LPS dysgenesis
Signs
 Unilateral (70%)
 Bilateral Ptosis (less)
 Absent upper lid crease
 Poor levator function.

11. Simple Congenital Ptosis
Compensatory chin elevation in severe bilateral cases.
In downgaze the Ptotic lid is
higher than normal
Poor LPS relaxation
A/w SR weakness(10%)
A/w Amblyopia along with Refractive error (20%) (Astigmatism)

12. Blepharophimosis Syndrome
AD inheritance
Also called BPES( Blepharophimosis Ptosis Epicanthus Syndrome)
Classical features:
Blepharophimosis: narrowing of horizontal palpebral aperture.
Normal 25-30mm. Usually 20-22mm in BPES
Ptosis
-With poor levator function
-Usually bilateral and symmetric and absent lid crease

13. Blepharophimosis Syndrome
Telecanthus: Increased Intercanthal distance
Epicanthus inversus: A fold of skin arising from lower eyelid and
growing over the medial canthus
Hypoplasia of nasal bridge and orbital rim

14. Marcus Gunn Jaw Winking
Seen in about 5% of all cases of congenital Ptosis manifest
Etiology:
Synkinetic innervation between levator (3rd CN) and masticatory
muscle ( 5th CN) i.e. mandibular division of the 5th cranial nerve is
misdirected to the levator muscle.

15. Marcus Gunn Jaw Winking
Common Signs:
Retraction of the ptotic lid in conjunction with stimulation of the
ipsilateral pterygoid muscles by chewing, sucking, opening the
mouth or 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

16. Grading of
Synkinesis
Subjective
(Maximum
Elevation of ptotic
lid)
Objective
(Measurment)
Mild Non ptotic position < 2mm
Moderate Upto superior limbus 2-5 mm
Severe Beyond superior
limbus with scleral
show
> 5mm
Marcus Gunn Jaw Winking

17. Marcus Gunn Jaw Winking

18. Acquired Ptosis
1. Aponeurotic Ptosis
It develops due to defects or dehiscence of the levator
aponeurosis in the presence of a normal functioning muscle.
 Senile/ Involutional ptosis
 Post traumatic
 Post surgical

19. Aponeurotic Ptosis
Good
levator
function
Higher
lid
crease
in RE
Absence
of lid
crease
Deep
Sulcus

20. Myogenic Ptosis
 Myasthenia Gravis
 Chronic progressive external ophthalmoplegia (CPEO)
 Myotonic Dystrophy
 Oculopharyngeal Muscular Dystrophy
 Ocular Myopathy

21. Myogenic Ptosis
Bilateral Ptosis is Myasthenia Gravis
Bilateral Ptosis is Myotonic dystrophy

22. Neurogenic Ptosis
It is caused by nerve innervational defect.
 3rd nerve palsy
 3rd nerve misdirection ( Aberrant Regeneration)
 Horner’s syndrome
 Ophthalmoplegic migraine
 Cerebral Ptosis ( Supra Nuclear lesion)
 Multiple sclerosis.( Nerve demelynation)

23. Neurogenic Ptosis
Left eye 3rd Nerve palsy

24. Neurogenic Ptosis
Basic features of Horner’s Syndrome
Ptosis
Miosis
Ipsilateral anhydrosis
Enopthalmos
Heterochromia iridis
Horner’s syndrome or oculosympathetic paresis results from an
interruption of the sympathetic nerve supply to the eye

25. Mechanical Ptosis
Mechanical ptosis is due to excessive weight on the upper lid or due to
lid scarring.
Excessive weight:
• Lid tumours
• Multiple chalazia
• Lid edema
• Dermatochalasis

26. Mechanical Ptosis
Cicatricial / Scarring Ptosis:
– Ocular pemphigoid
– Trachoma.

27. True Ptosis VS Pseudo Ptosis
True Ptosis
Dysfunction of Levator or
Muller muscle
Pseudo Ptosis
Lid appears to be inferiorly
displaced (Apparent eyelid
drooping)

28. Causes of Pseudo Ptosis
1. Lack of orbital volume:
- Micropthalmos
- Anopthalmos
- Pthisis bulbi

29. Causes of Pseudo Ptosis
2. Malposition of eye (Ipsilateral Hypotropia / Contra. Hypertropia
3. Enopthalmos

30. Causes of Pseudo Ptosis
4. Contralateral proptosis/ Contralateral lid
retraction
5. Dermatochalasis
6. Browptosis
7. Blepharospasm

31. Causes of Pseudo Ptosis
Ipsilateral Causes
Phthisis bulbi/ Anophthalmos
Enophthalmos/ Microphthalmia
Hypotropia
Dermatochalasis
Superior sulcus defect
Dermatochalasis/ Brow ptosis
Contralateral Causes
Buphthalmos
Proptosis
Upper eyelid retraction

32. Stepwise Ptosis Evaluation
1. History taking
2. Inspection
3. Ocular Examination
4. Ptosis Measurment
5. Other examinations (Ancillary test)
6. Decision making

33. History Taking (Step 1)
Age of onset?
-Since childhood/ Mid teen/
- Late teen/ Adult
Any variability in Ptosis?
- Yes/ No
- If yes then
- Diurnal variation/ Jaw winking/ Fatigueness

34. History Taking (Step 1)
Age of onset?
-Since childhood/ Mid teen/ Late teen/ Adult
Duration/ laterality?
- Recent onset/ long history
- Unilateral / Bilateral ( as reported by patient)
Any variability in Ptosis?
- Yes/ No
- If yes then
- Diurnal variation/ Jaw winking/ Fatigueness/ Rest- sleep

35. History Taking (Step 1)
Any predisposing factors?
-Past trauma/ Eye surgery/ Systemic Diseases/ Steroid Use
-Contact lens use
Any Family history?
-Yes/No
- If yes
- r/o BPES, MG, MD, CPEO, pharyngeal muscular dystrophy
Ask for Old photographs / Old clinical records?
- If available will help to compare the progression also predict the
onset

36. History Taking (Step 1)
Ask for the presence of any other associated features ?
-Diplopia
-Abnormal Head position
-Body muscle weakness
-Eye movement restrictions

37. Inspection (Step 2)
Closely inspect the patients extra ocular features before going to
the ocular examination
Laterality: Unilateral/ bilateral
Change in lid position with eye movement and jaw movement
Compare facial symmetry/ palsy
Abnormal head posture- head tilt/ face turn, chin up/ down
Overaction of Frontalis – Forehead crease

38. Inspection (Step 2)
Eyebrow position/ contour:
- r/o browptosis , dermatochalasis
Periocular inflammation
Proptosis/ Enopthalmos

39. Ocular Examination (Step 3)
Visual Acuity : (BCVA)
Refraction: Cycloplegic refraction
Slit lamp Examination
- r/o Exposure keratitis, Poor tear film
- Eye disorders (EOD)
Measure corneal sensitivity

40. Ocular Examination (Step 3)
 Examine Pupillary status
Iris color- Heterochromia
Ocular motility
Fundus examination/ Posterior segment
- r/o Abnormal pigmentation

41. Ptosis Measurement (Step 4)
Basically 6 clinical measurement techniques:
1. Vertical fissure height (VFH)
2. Margin reflex distance (MRD)
3. LPS action (Levator action)
4. Margin crease distance (MCD)
5. Margin Limbal distance (MLD)
6. Pre tarsal show

42. Vertical Fissure Height (VFH)
A.K.A Palpebral fissure height
It is the distance between the upper and lower lid margin measured
in the pupillary plane while fixating an distant object
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).

43. Vertical Fissure Height (VFH)
 VFH is measured in primary, upward and downward gaze
 Can be quantified by comparison with the contralateral side
 Difference from normal value in Bilateral Ptosis
Severity (Ptosis) Difference in VFH b/w two
eyes
Mild 2mm
Moderate 3mm
Severe 4mm or more

44. Vertical Fissure Height (VFH)
 VFH is measured in primary, upward and downward gaze
Up gaze accentuate
ptosis
Down gaze lid
lag
LE Ptosis in
primary position

45. Vertical Fissure Height (VFH)
 VFH is measured as shown in figure below

46. Margin Reflex Distance (MRD)
Total 3 types of margin to reflex distance is measured clinically
during Ptosis evaluation
- Margin reflex distance 1 (MRD 1)
- Margin reflex distance 2 (MRD 2)
- Margin reflex distance 3 (MRD 3)

47. Margin Reflex Distance 1
Margin-to-Reflex distance 1 (MRD1) :
 Distance from the central pupillary light reflex to the upper
eyelid margin with the eye in primary gaze.
NORMAL : 4 - 5 mm.
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.

48. Margin Reflex Distance 1
Severity of
Ptosis
Amount of
Upper eyelid
droop
Mild (B) 2mm
Moderate (C) 3mm
Severe (D) 4mm or more

49. Margin Reflex Distance 2
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

50. Margin Reflex Distance 3
 MRD3 is used to determine how much levator to resect in patients
with congenital Ptosis, who have a vertical strabismus associated
with ptosis and in whom strabismus surgery is not indicated.
 MRD3 is less frequently used when compared to MRD 1 or 2.
Margin reflex distance 3(MRD 3)
The distance between the corneal
light reflex and the centre of upper
eyelid margin in extreme up gaze.

51. LPS function (Burke’s method)
It is determined by the lid excursion caused by LPS muscle
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.

52. LPS function (Burke’s method)
Amount of
upper lid
excursion
Grade of
severity
15 mm Normal
8mm or more Good
5-7 mm Fair
4mm or less Poor

53. LPS function (Burke’s method)
Step 1
Step 2

54. How to access LPS action in
uncooperative childs?
Illif test:
Childs upper lid is everted while child is looking to downward
gaze
And on looking up ward the if the lid returns to normal
position it indicates presence of good levator function

55. Margin crease distance (MCD)
It is the distance from the upper eyelid crease to the upper eyelid
margin
Measured in downward gaze.
 The eyelid crease is formed by the insertion of the levator
Aponeurotic fibers into the upper eyelid skin.
Normal MCD is 8 to 9 mm in males and 9 to 11 in females.

56. Margin crease distance (MCD)
The lid crease is absent or shallow in patients with congenital ptosis
and higher in Aponeurotic Ptosis.
If there is a deeper upper lid sulcus on that side these should be noted
as signs of levator disinsertion.

57. Margin Limbal Distance (MLD)
(Putterman's method)
Margin limbal distance MLD (Putterman's method):
Is the distance between the center of the upper lid margin to the 6'o’
clock limbus in extreme upgaze

58. Pre tarsal show
Pre tarsal show :
It is the distance between the lid margin and the skin fold with the eyes
in the primary position.

59. Other Examinations (Step 5)
Lid lag
Bells phenomenon
Jaw winking phenomenon
Schirmer test , TBUT- dry eyes
Orthoptic evaluation

60. Bell’s Phenomenon
Checked by asking the patient to gently close the eyes while an
attempt is made to them by examiner
Eyes moves generally upwards and outwards on eyelid closure
Grade of Bell’s phenomenon Examination findings
Good > 2/3rd of cornea disappears
Fair 1/3 – 2/3 of cornea disappears
Poor <1/3rd of cornea disappears

61. Bell’s Phenomenon

62. Corneal sensation/TBUT TEST/
lagophthalmos test
The corneal sensation and lagophthalmos should be checked in all
Ptosis patients before planning for surgery.
Normal blink reflex and eyelid closure are essential to prevent dry
eye and exposure keratitis after Ptosis correction surgery.
Schirmer's test, tear film breakup time, and the tear meniscus
should be documented before surgery as the presence of a dry eye
may be a contraindication for Ptosis correction.

63. Ocular Motility Assessment
Orthoptic evaluation and Ocular motility test:
To r/o palsy and DRS
To r/o all causes of
pseudo ptosis
To find associated SR muscle weakness in Double elevator palsy
Strabismus must be corrected prior to the correction of ptosis.

64. Ancillary tests
Phenylephrine test: to see feasibility of Muller’s muscle surgery
Icepack test
Tensilon test
Fatigue/ sleep test
Others :
-Serum acetylcholine receptor assay
-EMG
-T3, T4, TSH

65. Phenylephrine test
Patients with minimal ptosis (2 mm or less)
should have a phenylephrine test performed in the
involved eye or eyes
Either 2.5 or 10% phenylephrine is instilled in
the affected eye or eyes. Usually two drops are
placed and the patient is reexamined 5 minutes
later.

66. Phenylephrine test
The MRD1 is rechecked in the affected and
unaffected eyes .
A rise in the MRD 1 by 1.5 mm or greater is
considered a positive test.
This indicates that Muller's muscle is viable so
operation to resect mullers muscle and
conjunctiva can relieve Ptosis.

67. Ice Pack Test
Safe speedy, easy test with relatively
high sensitivity and specificity
Ice pack placed over ptotic lid for 5
minutes
Ice palcement will enhance neuromuscular signal transmission at
myoneural junction
Improvent of ptosis (MRD 1) will indicate MG

68. Ice Pack Test
Before test During test After test

69. Sleep Test
Helps to confirm the diagnosis of MG
Patient suggested to sleep or give rest to his/ her lid for 30 minutes
Improvent of ptosis (MRD 1) after sleep indicates MG
Before sleep After sleep

70. Fatigue Test
Positive fatigue test will indicate MG

71. TensilonTest
Also called Edrophonium test
Pharmacological test to confirm myasthenia gravis

72. TensilonTest

73. TensilonTest
Edrophonium chloride inhibits acetylcholinesterase which prolongs
the presence of acetylcholine at the neuromuscular junction
This results in enhanced muscle strength
In ptosis a positive test is improvent of ptosis with in 2-5 minutes of
admistration of tensilon
No improvement beyond that time will cause negative test result

74. TensilonTest
Measure amount of ptosis
before injection and Inject
i.v. atropine 0.3 mg before
Edrophonimum injection
Inject i.v. test dose of
edrophonium
(2 mg) and Inject remaining
(8 mg) if no
hypersensitivity
Before Injection Positive test result

75. Final Diagnosis
Do a quick assessment!!!
Unilateral/ bialteral
 Congenital/ Acquired
Acute onset/ Chronic disorder
Progressive / Non progresive
Isolated / Systemic association

76. Ptosis Surgery Summary
Mild ptosis (=<
2mm)
Moderate
ptosis (3mm)
Severe ptosis
(>= 4mm)
Good LPS
action
(>=8mm)
Fasanella servat LPS resection LPS resection
Fair LPS
action
(5-7)mm
LPS resection LPS resection LPS resection
Poor LPS
action
(<=4mm)
------- Frontalis Sling Frontalis Sling

77. Case presentation
Age : 10/F
C/0 dropping of right eye upper lid since birth
No History of ptosis progression
No history of variation
No any systemic illness
No past history of trauma and surgery

78. Case presentation
Ocular Examination and Inspection:
BCVA: 6/6 OU
IOP: 13mm Hg RE and 15 mm Hg LE
Pupil: R/R/R
Anterior segment : WNL
Posterior Segment : WNL
No abnormal head posture
Brow position: slightly lifted in RE
Lid crease: faintly present in RE

79. Case presentation
Ptosis Evaluation:
Test procedure RE LE
Vertical Fissure Height (VFH) 5mm 12mm
Margin Reflex Distance 1( MRD 1) - 1mm 5mm
Margin Reflex Distance 2( MRD 2) 6mm 7mm
LPS function 4mm 20mm
Orthoptic Evaluation:
Full EOM with No strabismus

80. Case presentation
Ptosis evaluation with Berke’s method (LPS function) :

81. Case presentation
Lid Lag (RE) Normal Bell’s Phenomenon (RE)

82. Case presentation
No Marcus Gunn Jaw Winking
Ancillary
test
performed
OD OS
Schirmer’s
Test
35mm in 3
minutes
35mm in
3minutes
Corneal
Sensation
Normal Normal

83. Case presentation
Diagnosis :
RE severe congenital ptosis with poor LPS function without
MGJWP
Advice :
Surgery ( RE Frontalis Sling Operation)
Post OP finding:
Slight Lagopthalmos with lid lag in down gaze

84. References
1. A.K. Khurana Clinical Ophthalmology
2. Clinical Ophthalmology by J.J kanski
3. Wills Eye Manual
4. Internet
5. Case Courtesy ( Dr. Sabin Shau’s presentation)