To know about various type of ptosis. Ptosis measurement procedure

1. Clinical Evaluation Of Ptosis
Md . Azizul Islam
Junior Optometrist
Oculoplasty Department (IIEI&H)
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2. DEFINITION
 Abnormal drooping of upper eyelids is called
ptosis.
 Normally upper eyelid covers 2mm of cornea.
 Therefore in ptosis it covers more than 2mm.
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3. CLASSIFICATION OF PTOSIS
A. Congenital
B. Acquired
I. Neurogenic
II. Myogenic
III. Mechanical
IV. Traumatic
C. Pseudotosis
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4. Congenital ptosis
 It is associated with congenital weakness (maldevelopment)
of the levator palpebral superior (LPS) muscle.
1.Simple congenital ptosis :
Not associated with any other anomaly.
congenital ptosis with associated weakness of superior
rectus muscle.
2.Blepharophimosis syndrome:
 which comprises congenital ptosis, blepharophimosis,
telecanthus and epicanthus inversus .
3.Congenital synkinetic ptosis :
 (Marcus Gunn jaw winking pheno menon).
 Its the condition of misdirection 3rd nerve , retruction of the
upper lid with various ocular movements.
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5. Acqured Ptosis
• Third nerve palsy
1. Neurogenic
• Third nerve misdirection
• Horner syndrome
• Myasthenia gravis
• Ocular myopathies
• Simple congenital
2.Myogenic
• Blepharophimosis syndrome
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6. 3.Mechanical ptosis
Due to excessive weight on the upper lid
 lid tumours,
 multiple chalazion .
 lid oedema.
4.Traumatic ptosis:
Trauma to levator muscle, post surgies.
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7. Mechanical/Traumatic ptosis
Dermatochalasis Large tumours
Severe lid oedema due to Tr. Tr.Anterior orbital lesions
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8. PSEUDOPTOSIS
 Pseudoptosis is the appearance of
ptosis in the absence of levator
abnormality.
 Exclude pseudoptosis (simulated
ptosis) on inspection.
 Its common causes are:
 Microphthalmos,
 Anophthalmos,
 Endophthalmos
 Phthisis bulbi.
 Double elevator palsy
 Blepharospasm
 Contralateral proptosis
Due to phthisis Bulbi
Due to Contralateral proptosis
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9. HISTORY
 Ptosis
 Age of onset
 Duration
 One/both eye
 Diurnal variability
 Associated history :
 Diplopia
 Fatigability
 Variable
 Muscle weakness
 Vision
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10.  Association 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?
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11. This is a test for determining corneal reflex, if the
eyes are in alignment, You shine a light at the eyes
and observe where the light reflex is located in
reference to the pupil. Its may Central , Eccentric ,
In ward , Out ward.
HB / CL Reflex
Measurments of Ptosis
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12. Upper lid crease
• Distance between lid margin and lid
crease in down-gaze.
• Normal-females 10 mm; males 8 mm.
• Absence in congenital ptosis indicates
poor levarator function.
Distance between lash
line and skin fold in
primary position of
gaze.
Pretarsal show
crease fold
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13. Measurements Of MRD
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
Mild ptosis (2 mm )
Moderate ptosis (3 mm)
Severe ptosis (4 mm or more)
(MRD)
Normal MRD
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14. Measurements LPSA
Levator Palpebral Supirior Action(LPSA)
• 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
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15. Measurements PFH
Palpebral fissure height(PFH)
• Distance between upper and lower lid margin
• Normal:
– Women: 8-12 mm
– Men: 7-10 mm
N.B: Upper lid margin rests about 2mm below upper
limbus and Lower lid margin 1mm above lower
Limbus. So we determind amount of unilateral ptosis
by PFH. IIEI&H

16. Bell’s phenomenon
Upward rotation of globe on lid closure
Good Poor - risk of postoperative
corneal exposure
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17. Marcus Gunn jaw winking pheno-
menon (MJWP).
Its the condition of misdirection 3rd nerve ,
retruction of the upper lid with various
ocular movements
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18.  Ocular Motility:
 Importance in myogenic ptosis,
 To R/O 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.
 Pupillary Examination:
 To diagnosis Horner’s syndrome
 Involvement in a case of third nerve palsy
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19. Documentation of ptosis
mesurements
 HB –Reflex :Central , Eccentric , In ward , Out ward.
 Lid Crease :10 mm / 8 mm.
 MRD : mild 2 mm , moderate 3 mm, severe 4 mm.
 LPSA : 15 mm normal,8-12 mm good,5-11 mm fair,
<4 mm poor.
 PFH : 8-10, 7-9 mm
 Bell’s phenomenon : Good, Poor.
 Ocular motility : full, restricted.
 MGJWP : + (ve), - (ve) .
 Corneal sensitivity : Good, fair.
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20. Documentation…..
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21. Documentation…..
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22. TREATMENTS
Non-surgical – Rehabilitative crutch glasses
Surgical - Definitive Treatment
Decision making
When to operate Which
procedure
 concern is cosmetic any age.
 concern is amblyopia early surgery.
squint has to be operated first.
Blepharophimosis, telecanthus, epicanthus operated
first
Depends on levator
function + associated
anomaly
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23. Pre - oparative Ptosis Post oparative ptosis
Results of ptosis Sx
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24. References
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 Congenital Ptosis". MEDgle. Retrieved 2008-10-20.
 Adult Ptosis at eMedicine
 "Eye Ptosis Congenital". Retrieved 2010-06-14.
 Finsterer, J (2003). "Ptosis: causes, presentation, and
management". Aesthetic Plastic Surgery.
 Pic: Google + Me.

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