ptosis slides

1. PTOSIS
NIRAV B.DADIA
FELLOW
NANDADEEP EYE
HOSPITAL

2. Functional anatomy
• Levator palpebrae superioris (LPS):
– It 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.

4. Muller’s muscles:
– 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

5. • Frontalis & orbicularis oculi:
– frontalis muscle and the orbicularis oculi,
both 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

7. PTOSIS
• Ptosis (from Greek Ptosis -to "fall") is a drooping
or falling of the upper or lower eyelid.
• Normally upper eyelid covers 1/6th of cornea i.e.
2mm
• Therefore in ptosis it covers more than 2mm

9. EVALUATION
OF PTOSIS

10. NORMAL POSITION OF EYELIDS
• The normal upper eyelid in primary position
– crosses the iris between 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.
• The palpebral fissures:
– are normally 9 mm to 12 mm from upper to lower lid
margin.

12. HISTORY
• Age of onset
• Duration
• Unilateral/bilateral
• Weather ptosis worsen through the day
• Diplopia
• Muscle weakness
• trauma/ surgery
• lid edema
• previous ptosis surgery

13. • Presence of any aberrant lid movements
• Weather eye movements are impaired
• Past medical history
• Current medications
• Family history
• Old photographs

14. • Associated history :
– Diplopia
– Muscle weakness

15. EXAMINATION
• Head posture
• Periocular fullness
• Frontalis overaction
• Scar mark
• Lid skin laxity
• Telecanthus, epicanthus inversus

16. 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.
Pupillary Examination:
– TO diagnosis Horner’s syndrome
– Involvement in a case of third nerve palsy
Visual Acuity

17. Refraction-
• Cycloplegic test refraction is indicated in all children
with ptosis since it is known that a significant number
have anisometropia primarily due to astigmatism on
the ptotic side.
• Any significant refractive error should be corrected
• Best-corrected visual acuity should be assessed to
record any amblyopia if present, especially in cases of
congenital ptosis

18. • Complete /incomplete
• Total unilateral ptosis
– complete third nerve palsy.
• Mild to moderate unilateral ptosis
– Horner's syndrome,
– partial third nerve palsy.
• Mild to moderate bilateral ptosis
– neuromuscular disorders, such as MG,
– muscular dystrophy,
– Ocular myopathy.

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

20. MEASUREMENTS
Margin reflex distance 1(MRD 1)-
After shining the torchlight in the patient eye,
the distance between the corneal light reflex
to the centre of the upper lid margin is
measured.
Normal value is 4- 4.5mm.

22. 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

24. • Margin reflex distance 3(MRD 3)- the distance
between the corneal light reflex and the
centre of upper eyelid margin in extreme
upgaze.

26. • Also it is important to measure the PFH in
downgaze.
• As reduced ptosis/ lid lag is seen in congenital
ptosis as the dystrophic muscle neither
contracts nor relaxes.

28. Margin crease distance(MCD)
• It is an important anatomical landmark, which give clue to levator
action
• It is measured with patient looking down, distance from the central
eyelid margin to the most prominent lid crease.
• Normal value in Men 5-7mm,
women 8-10mm
• Crease is absent in congenital ptosis and higher in aponeurotic
ptosis.

30. • An absent lid crease is often accompanied by
poor levator function.
• If a lid crease is present, but higher than
normal and if there is a deeper upper lid
sulcus on that side these should be noted as
signs of levator disinsertion

31. MARGIN LIMBAL DISTANCE-
• It gives the degree of loss of Levator action.
• It is measured as the distance between the
centre of upper lid margin to 6o’clock limbus
in extreme upgaze
• Normally it is 9mm.

33. Levator function test-
• Excursion of upper eyelid from extreme
downgaze to extreme upgaze is a measure of
LPS function, negating the action of frontalis
muscle (Berke’s method).

36. ILLIF’s test
• Used in children
• Pt upper lid is everted in downgaze. On
looking up, the lid should return to normal
position if levator action is good

37. BELL’S PHENOMENON
• The eyes moves generally upwards and
outwards on eyelid closure. It is extremely
important in assessing post-operative corneal
complications.
• Poor bells phenomenon invariably warrants
under correction.

40. • Corneal sensation- always check before planning
the surgery.
• Schirmers test – to rule out dry eye disease
• Pupillary abnormalities-1)miosis in horner’s
syndrome
2)mydriasis in 3rd nerve palsy.
Look for any associated mass lesion causing
mechanical ptosis

41. Photographic documentation-
• It is the most important aspect of ptosis
evaluation.
• Review of old photographs gives clue to the
duration and nature of ptosis.

42. PTOSIS
CLASSIFICATION
CONGENITAL
ACQUIRED
PSEUDOPTOSIS

43. A. Congenital
B. Acquired
1) Neurogenic
2)Myogenic
3) Aponeurotic
4)Mechanical
5)Neurotoxic
C. Pseudotosis

44. CONGENITAL
It is associated with congenital weaknes
(maldevelopment) of the levator palpebrae superioris
(LPS).
Simple ptosis
Associated with Superior Rectus weakness
With blepharophimosis syndrome
Synkinetic ptosis – Marcus Gun Jaw Winking
ptosis,

46. Management
• Management of BPES is primarily surgical
• Care should be given to treat assoicated amblyopia.
• The usual sequence of surgical treatment is
-correction of the epicanthic folds at about the age of 3–4 years and
- correction of the ptosis about 9–12 months later. Early surgery may be
necessary for amblyopia .
• Epicanthus fold and telecanthus :
• Double Z or Y-Z plasties, transnasal wiring or plating of the medial canthal
tendons.
• Ptosis:
• Usually is corrected with a brow suspension procedure (frontalis sling).
• One stage correction of the telecanthus, epicanthic folds and the ptosis has
been reported, although often a staged approach is done.

47. MARCUS GUNN PHENOMENON
– The stimulation of the trigeminal nerve by
contraction of the pterygoid muscles of jaw
results in the excitation of the branch of the
oculomotor nerve that innervates the LPS
ipsilaterally, so the patient will have rhythmic
upward jerking of their upper eyelid.

49. Grading of marcus gunn phenomenon
• Mild- elevation of ptotic eyelid to non- ptotic
position
• Moderate- maximum elevation goes upto
superior limbus
• Severe- maximum elevation beyond the
superior limbus with scleral show

50. MARCUS GUNN PHENOMENON
•
Marcus Gunn Ptosis constitutes about 4-5% of all congenital ptosis.
Management of the condition is challenging.
• A single stage surgical technique of bilateral levator excision with
bilateral fascia lata sling surgery is presented.
• The technique eliminates jaw winking, maintains symmetry,
provides excellent aesthetics by avoiding contour and lid position
abnormalities, as no tarsal fixation of the sling is required.

51. ACQUIRED PTOSIS
Neurogenic- 3rd nerve palsy, horner syndrome.
Myogenic- myasthenia gravis, Myotonic
dystrophy.
Aponeurotic- involutional, post surgical
Mechanical- tumour, swelling.

52. Neurogenic ptosis
It is caused by innervational defects such
• 3rd nerve palsy,
• 3rd nerve misdirection
• Horner’s syndrome,
• Cerebral ptosis
• Multiple sclerosis.

53. Third nerve palsy
• Vascular disorders such as diabetes, heart
disease, atherosclerosis and aneurysm,
particularly of the posterior communicating
artery.
• Space occupying lesions or tumours, both
malignant and non-malignant.
• Inflammation and infection.
• Trauma.
• Demyelinating disease (multiple sclerosis)

54. Management
It is recommended to wait at least 6 months for resolution.
• The patient needs to be examined periodically by then, and if some improvement
is seen, further recovery could be seen up to 1 year post incident.
•
• With a complete ptosis, diplopia is not an issue but may require occlusion if the
ptosis is partial.
• In children, amblyopia needs to be addressed with patching and lid elevation with
tape or a glasses crutch.
• Light sensitivity with a dilated pupil may be controlled with pilocarpine drops.
• Botulinum toxin has been used in the lateral rectus with limited usefulness in the
short term.

55. Management
• Patients who do not recover
from third cranial nerve palsy after 6-12
months may become candidates for
strabismus surgery (eye muscle resection or
recession) to treat persistent and stable-angle
deviation.

57. Horner's syndrome
• Horner's syndrome, also known as oculosympathetic paresis, is a
combination of symptoms that arises when a group of nerves
known as the sympathetic trunk is damaged.
•
• The signs and symptoms occur on the same side (ipsilateral)
• It is characterized by
• miosis (a constricted pupil),
• partial ptosis (a weak, droopy eyelid),
apparent anhydrosis (decreased sweating),
• with apparent enophthalmos (inset eyeball).[2]

59. Phenyl ephrine test
• Patients with minimal ptosis (2 mm or less) should have a
phenylephrine test performed in the involved eye
• 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.
• The MRD1 is rechecked in the affected and unaffected eyes .
• A rise in the MRDl of 1.5 mm or greater is considered a positive
test.
This indicates that Müller's muscle is viable

60. • The treatment of Horner syndrome depends
on the location and cause of the lesion or
tumor.
• In some cases surgical removal of the lesion or
growth may be appropriate.
• Radiation and chemotherapy may be
beneficial to patients with malignant tumors.

61. Cerebral ptosis
• It is due to supranuclear lesions.
• Unilateral cerebral ptosis occurs with lesions,
usually ischemic, of the opposite hemisphere,
and is more common with right hemisphere
lesions.
• Bilateral supranuclear ptosis may occur with
unilateral or bilateral hemispheric lesions.
• Ptosis has been reported in as many as 37.5%
of patients with hemispheric strokes.

62. MYOGENIC PTOSIS
• It is due to acquired disorders of the LPS
muscle or of the myoneural junction.
1. Myasthenia gravis
2. Myotonic dystrophy
3. Ocular myopathy
4. following trauma to the LPS muscle.

63. Myasthenia Gravis
• The ptosis in Myasthenia Gravis is frequently asymmetric
and may be unilateral, though it will tend to shift from side
to side
• It characteristically fluctuates from moment to moment and
is worsened by prolonged upgaze (fatiguable ptosis).
• Cogan's lid twitch sign, – characteristic of myasthenia,
consists of a brief overshoot twitch of lid retraction
following sudden return of the eyes to primary position
after a period of downgaze.

65. • Curtain sign, seesaw ptosis: –
• When the ptosis is asymmetric, the driving
discharges attempting to keep the more ptotic
eyelid open are also transmitted, per Hering's
law, to the less ptotic eyelid.
• – Manually raising the more ptotic lid causes
relaxation and the eye with less ptosis,
sometimes even no ptosis, may suddenly
crash.

67. Myasthenia Gravis
1. Investigations
• Edrophonium (Camiston) test
• Electromyography to confirm fatigue
• Antibodies to acetylcholine receptors
• CT or MRI for presence of thymoma

70. ICE TEST
An ice pack is applied to the affected upper eyelid for 5
minutes.
A positive test is the improvement of ptosis by > 2mm or
more.
This transient improvement in ptosis is due to the cold
decreasing the acetylcholinesterase break-down of
acetylcholine at the neuromuscular junction.
More acetylcholine collects in the junction and therefore
increases the muscle contraction

72. MYASTHENIA GRAVIS
Treatment options
• Medical - anticholinesterases, steroids and
azathioprine
Neostigmine: Initial dose: 0.03 to 0.07 mg/kg
IV over a period of at least 1 minute
Maximum dose: 0.07 mg/kg IV or up to a total
of 5 mg IV, whichever is less
• Thymectomy

76. APONEUROTIC PTOSIS
• It develops due to defects of the levator
aponeurosis in the presence of a normal
functioning muscle.
• It includes
– involutional (senile) ptosis,
– postoperative ptosis
– Post traumatic dehiscence or disinsertion of
the aponeurosis.

77. Senile ptosis
• Senile or involutional ptosis is very common.
Asymmetric lids and redundant lid tissue in the elderly.
• The levator aponeurosis attaches the levator muscle to the tarsal
plate, which forms the eyelid.
• Aging may cause levator dehiscence disinsertion (LDD)—with
stretching, thinning, or detachment of the aponeurosis.
• Normally, with the eyelids gently closed, the upper lid margin lies 5
mm to 7 mm below the upper lid fold (the skin fold at the upper
part of the lid).
• An increase in this distance suggests LDD.

79. MANAGEMENT
• Anterior levator aponeurotic-muscle
reattachment or resection is effective.
• Some surgeons perform a posterior resection
of Müller's muscle in patients who
demonstrate adequate elevation of the eyelid
following instillation of topical phenylephrine.

80. Mechanical ptosis
• Due to excessive weight on the upper lid
– lid tumours
– multiple chalazia
– lid oedema.
• Cicatricial Ptosis
– ocular pemphigoid
– trachoma.

82. Pseudoptosis
• Ipsilateral hypotropia
• Enopthalmos
• Dermatochalasis
• Double elevator palsy
• Brow ptosis
• Blepharospasm
• Contralateral lid retraction
• Contralateral exopthalmos

84. SURGICAL
MANAGEMENT

85. Mild Ptosis
Phenylepherine
+ve
Mullerectomy
Fasanella
servat
Phenylepherine
-ve
Blepharoplasty
Levator
resection

86. Ptosis
Moderate
Levator
resection
Levator
Advancement
Severe
Frontalis
Sling

87. • So we should examine case of ptosis carefully
before proceeding for surgical management,
to avoid any post operative surprise.