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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
PTOSIS
• Pseudoptosis
• True ptosis
1. Evaluation
• Neurogenic ptosis
• Myogenic ptosis
• Aponeurotic ptosis
• Mechanical ptosis
2. Classification
3. Treatment options
Causes of pseudoptosis
Ipsilateral hypotropia Brow ptosis - excessive
eyebrow skin
Dermatochalasis - excessive
eyelid skin
Lack of lid support Contralateral lid retraction
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)
• 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)
• 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
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
Bell’s phenomenon
Upward rotation of globe on lid closure
Good Poor - risk of postoperative
corneal exposure
Left third nerve palsy
Severe unilateral ptosis and
defective adduction Normal abduction
Defective elevation Defective depression
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
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
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
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
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
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
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
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
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
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
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
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
Mechanical ptosis
Causes
Dermatochalasis Large tumours
Severe lid oedema Anterior orbital lesions
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
..
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
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

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ptosis

  • 1. 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
  • 2. PTOSIS • Pseudoptosis • True ptosis 1. Evaluation • Neurogenic ptosis • Myogenic ptosis • Aponeurotic ptosis • Mechanical ptosis 2. Classification 3. Treatment options
  • 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
  • 8. Bell’s phenomenon Upward rotation of globe on lid closure Good Poor - risk of postoperative corneal exposure
  • 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
  • 22. Mechanical ptosis Causes Dermatochalasis Large tumours Severe lid oedema Anterior orbital lesions
  • 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