Upper Lid Ptosis
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The diagnosis and management of blepharoptosis
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Upper Lid Ptosis
- 1. Upper Lid Ptosis Ea Raksmey First Year Resident
- 2. Outline • Definition • Classification • Measurements • Diagnosis • Differential Diagnosis • Management
- 3. Definition • Blepharoptosis or eye lid ptosis is an abnormally low position of the upper eye lid
- 4. Classification • Causes: • Congenital • Acquired • Mechanisms: • Neurogenic • Myogenic • Aponeurotic • Mechanical
- 5. Measurements Margin-reflex distance (MRD) • MRD1: distance between upper lid margin and CLR. N: 4-4,5 mm • MRD2: distance between lower lid margin and CLR. N: 5-5,5 mm
- 6. Measurements Palpebral fissure height •Distance between upper and lower lid margin •Normal: – Women: 8-12 mm – Men: 7-10 mm •Upper lid: 2mm below sup. limbus •Lower lid: 1mm above inf. Limbus
- 7. Measurements Levator function •Place thumb against brow to stop frontalis •Patient look down •Then look up •Measure with a ruler •Results: – >15mm: normal – 12-14 mm: good – 5-11 mm: fair – <4 mm: poor
- 8. Measurements Upper eye lid crease •Veritcal margin of lid crease and lid margin in downgaze •Normal: – Women: 10 mm – Men: 8 mm
- 9. Measurements Lagophthalmos •Inability to close eye lids completely •7th nerve palsy
- 10. Neurogenic Ptosis Congenital ptosis •CN III palsy – Ptosis + inability to elevate, depress and adduct globe •Congenital Horner syndrome – Miosis, anhidrosis, decrease pigmentation of iris •Marcus Gunn jaw-winking syndrome – Unilateral ptosis, elevated with jaw movements
- 11. Neurogenic Ptosis Marcus Gunn jaw-winking Sd Horner Sd
- 12. Neurogenic Ptosis Acquired ptosis •CN III palsy – Ischemic or compressive – Pupil or non-pupil involved •MG – Ptosis worsens with fatigue – Eye fatigability test – Ice pack test – Acetylcholine receptor AB test
- 13. Myogenic Ptosis Congenital ptosis •Malformation of levator muscle •Fibrous and adipose tissue replace muscle •Signs: – Decrease levator function – Eye lid lag – Lagophthalmos – Upper lid crease absent or poorly formed – Downgaze ptotic eye lid higher than fellow eye
- 14. Myogenic Ptosis MRD1 RE: 5 mm LE: 1 mm Upgaze accentuate ptosis Downgaze lid lag
- 15. Myogenic Ptosis Acquired Ptosis •Localized or diffuse muscular dystrophy •Chronic progressive external ophthalmoplegia •MG •Oculopharyngeal dystrophy
- 16. Aponeurotic Ptosis • Involutional attenuation • Repetitive traction (rubbing, contact lenses, surgery) • Signs: • High or absent upper lid crease • Thinning of eye lid • Good levator function • Worsen in downgaze
- 17. Aponeurotic Ptosis Good levator function Eye lid drop in downgaze RE aponeurotic ptosis after cataract surgery
- 18. Mechanical Ptosis Cogenital ptosis •Plexiform neuroma •Hemangioma Acquired ptosis •Chalazion •Skin carcinoma •Lid masses •Trauma
- 19. Differential Diagnosis Pseudoptosis •Lack of support (artificial eye, microophthalmos…) •Controlateral lid retraction •Ipsilateral hypotropia •Brow ptosis •Dermatochalasis Brow ptosis Lid retraction Ipsilateral hypotropia
- 20. Management • Non surgical: • Eye lid crutches • Treat causes of mechanical ptosis • Surgical: • External (transcutaneous) levator advancement • Internal (transconjunctival) levator/tarsus/Müller resection • Fronatlis muscle suspension
- 21. External Levator Advancemnt • Indications • Levator function normal • Lid crease is high
- 23. Frontalis muscle suspension • Indications: • Severe ptosis (>4mm) poor levator function (<4mm) • Marcus Gunn • Blepharophimosis • CN III palsy • Unsatisfactory result from previous levator resection
- 24. Frontalis muscle suspension A. Site of incision marked B. Threading of fascia lata strip C. Tightening and tying of strip
- 25. Surgery