This document discusses the classification and evaluation of ptosis (drooping of the upper eyelid). Ptosis can be neurogenic, myogenic, aponeurotic, mechanical or pseudoptosis. Common causes include third nerve palsy, Horner syndrome, myasthenia gravis, and congenital conditions. Evaluation involves measuring the marginal reflex distance, levator function, and upper lid excursion. Treatment depends on the type and severity of ptosis, and may include procedures like levator resection or frontalis brow suspension.
3. Causes of pseudoptosis
Ipsilateral hypotropia Brow ptosis - excessive
eyebrow skin
Dermatochalasis - excessive
eyelid skin
Lack of lid support Contralateral lid retraction
4. 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)
5. • 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)
6. • 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
7. 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
9. Left third nerve palsy
Severe unilateral ptosis and
defective adduction Normal abduction
Defective elevation Defective depression
10. 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
11. 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
12. 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
13. 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
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. 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
17. 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
18. 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
19. 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
20. Blepharophimosis syndrome
• Rare congenital disorder
• Dominant inheritance
• Moderate to severe symmetrical ptosis
• 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
21. 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
23. 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
..
24. 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
25. 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