Ptosis- causes and management

1. Dr. Christina Samuel
Postgraduate Ophthalmology
MMCH & RI

2. OBJECTIVES
 DEFINITION
 TYPES
 EXAMINATION
 TREATMENT

3. DEFINITION
 Abnormal drooping of upper eyelids is called ptosis
 Normally upper eyelid covers 1/6th of cornea ie,. 2mm
 Therefore in ptosis it covers more than 2mm

4. TYPES OF PTOSIS
 1.CONGENITAL PTOSIS
 #simple congenital ptosis
 #blepharophimosis syndrome
 #marcus gunn jaw winking ptosis(congenital
synkinetic ptosis)
 2.ACQUIRED PTOSIS
 #neurogenic ptosis
 #myogenic ptosis
 #aponeurotic ptosis
 #mechanical ptosis

5. CLASSIFICATION OF PTOSIS
• Third nerve palsy
1. Neurogenic
• Third nerve misdirection
• Horner syndrome
• Marcus Gunn jaw-winking syndrome
• Myasthenia gravis
• Myotonic dystrophy
• Ocular myopathies
• Simple congenital
2. Myogenic
3. Aponeurotic
4. Mechanical
• Blepharophimosis syndrome

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

7. Blepharophimosis syndrome
• Rare congenital disorder
• Dominant inheritance
• Moderate to severe symmetrical pto
• 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

8. Marcus Gunn jaw-winking syndrome
• Accounts for about 5% of all cases of congenital ptosis
• Retraction or ‘wink’ of ptotic lid in conjunction with
stimulation of ipsilateral pterygoid muscles
Opening of mouth Contralateral movement of jaw

9. Left third nerve palsy
Severe unilateral ptosis and
defective adduction Normal abduction
Defective elevation Defective depression

10. Bell’s phenomenon
Upward rotation of globe on lid closure
Good Poor - risk of postoperative
corneal exposure

11. Right third nerve misdirection
• Rare, unilateral
• Aberrant regeneration following acquired third nerve palsy
• Pupil is occasionally involved
• Bizarre movements of upper lid accompany eye movements
Right ptosis in primary
position
Worse on right gaze Normal on left gaze

12. Horner syndrome
• Caused by oculosympathetic
palsy
• Usually unilateral mild
ptosis and miosis
• Slight elevation of lower lid
• Normal pupillary reactions
• Iris hypochromia if
congenital or longstanding
• Anhydrosis if lesion is below
superior cervical ganglion

13. Important causes of Horner syndrome
Central
(first order neurone)
• Brainstem disease
(vascular, demyelination)
• Spinal cord disease
(syringomyelia, tumours)
Pre-ganglionic
(second order neurone)
• Intrathoracic lesions
(Pancoast tumour, aneurysm)
• Neck lesions
(glands, trauma)
Post-ganglionic
(third order neurone)
• Internal carotid artery disease
• Cavernous sinus mass
Posterior hypothalamus
Ciliospinal centre of
Budge( C8 - T2 )
Superior cervical
ganglion

14. Myasthenia Gravis
• Uncommon, typically affects young women
1 Clinical features.
• Edrophonium (Camiston) test
2. Investigations
• Medical - anticholinesterases, steroids and azathioprine
3. Treatment options
• Weakness and fatiguability of voluntary musculature
• Three types - ocular, bulbar and generalized
• Antibodies to acetylcholine receptors
• CT or MRI for presence of thymoma
• Electromyography to confirm fatigue
• Thymectomy

15. 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

16. Myotonic dystrophy
Facial weakness and
ptosis
• Involvement of tongue and pharyngeal muscles
• Ophthalmoplegia - uncommon
• Muscle wasting • Hypogonadism
• Frontal baldness in males
• Intellectual deterioration
• Presenile stellate cataracts
Release of grip difficult

17. Ocular myopathies
• Isolated
• Oculopharyngeal dystrophy
• Kearns-Sayre syndrome
(pigmentary retinopathy)
• Ptosis - slowly progressive and
symmetrical
• Ophthalmoplegia - slowly
progressive and symmetrical
(no diplopia)
Clinical types Ocular features

18. Aponeurotic ptosis
• Weakness of levator aponeurosis
• Causes - involutional, postoperative and blepharochalasis
High upper lid crease Good levator function
Absent upper lid crease Deep sulcus
Mild
Severe

19. Mechanical ptosis
Causes
Dermatochalasis Large tumours
Severe lid oedema Anterior orbital lesions

20. Causes of pseudoptosis
Ipsilateral hypotropia Brow ptosis - excessive
eyebrow skin
Dermatochalasis - excessive
eyelid skin
Lack of lid support Contralateral lid retraction

21. Marginal reflex distance
• Distance between upper lid
margin and light reflex (MRD)
• Mild ptosis (2 mm of droop)
• Moderate ptosis (3 mm)
• Severe ptosis (4 mm or more)

22. • Reflects levator function
• Normal (15 mm or more)
• Good (12 mm or more)
• Fair (5-11 mm)
Upper lid excursion
• Poor (4 mm or less)

23. • Distance between upper and lower lid margins
• Normal upper lid margin rests about 2 mm below upper limbus
• Normal lower lid margin rests 1 mm above lower limbus
• Amount of unilateral ptosis is determined by comparison
Vertical fissure height

24. Upper lid crease
• Distance between lid margin and lid
crease in down-gaze
• Normals - females 10 mm; males 8 mm
• Absence in congenital ptosis indicates
poor levator function
• High crease suggests an aponeurotic
defect
• Distance between lash line and skin fold
in primary position of gaze
Pretarsal show
crease fold

25. Edrophonium 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
Before injection Positive result

26. Fasanella-Servat procedure
Excision of upper border of tarsus, lower border of Muller muscle
and overlying conjunctiva
Indicated for mild ptosis with good levator function
..

27. Levator resection
Shortening of levator complex
Indicated for any ptosis provided levator function is at least 5 mm
Amount determined by levator
function and severity of ptosis

28. Frontalis brow suspension
Attachment of tarsus to frontalis muscle
with sling
Main indications
• Severe ptosis with poor levator function ( 4 mm or less )
• Marcus Gunn jaw-winking syndrome

29. THANK U