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Upper Lid Ptosis

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Upper Lid Ptosis

  1. 1. Upper Lid Ptosis Ea Raksmey First Year Resident
  2. 2. Outline • Definition • Classification • Measurements • Diagnosis • Differential Diagnosis • Management
  3. 3. Definition • Blepharoptosis or eye lid ptosis is an abnormally low position of the upper eye lid
  4. 4. Classification • Causes: • Congenital • Acquired • Mechanisms: • Neurogenic • Myogenic • Aponeurotic • Mechanical
  5. 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. 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. 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. 8. Measurements Upper eye lid crease •Veritcal margin of lid crease and lid margin in downgaze •Normal: – Women: 10 mm – Men: 8 mm
  9. 9. Measurements Lagophthalmos •Inability to close eye lids completely •7th nerve palsy
  10. 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. 11. Neurogenic Ptosis Marcus Gunn jaw-winking Sd Horner Sd
  12. 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. 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. 14. Myogenic Ptosis MRD1 RE: 5 mm LE: 1 mm Upgaze accentuate ptosis Downgaze  lid lag
  15. 15. Myogenic Ptosis Acquired Ptosis •Localized or diffuse muscular dystrophy •Chronic progressive external ophthalmoplegia •MG •Oculopharyngeal dystrophy
  16. 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. 17. Aponeurotic Ptosis Good levator function Eye lid drop in downgaze RE aponeurotic ptosis after cataract surgery
  18. 18. Mechanical Ptosis Cogenital ptosis •Plexiform neuroma •Hemangioma Acquired ptosis •Chalazion •Skin carcinoma •Lid masses •Trauma
  19. 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. 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. 21. External Levator Advancemnt • Indications • Levator function normal • Lid crease is high
  22. 22. Internal Levator/Tarsus/Müller resction
  23. 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. 24. Frontalis muscle suspension A. Site of incision marked B. Threading of fascia lata strip C. Tightening and tying of strip
  25. 25. Surgery

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