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blepharoptosis

Dr.Dhivya pratheepa
Blepharoptosis
• Greek word : to fall
• Is abnormal infero displacement of
  upper eye lid
classificaton
classification
Neurogenic            Myogenic
• Third nerve palsy   •   Myasthenia gravis
• Horner’s syndrome   •   Myotonic dystrophy
                      •   OPMD
                      •   CPEO
classification
Aponeurotic          Mechanical
• Involutional       •   Tumor
• Post operative     •   Dermatochalasis
                     •   Oedema
                     •   Scarring
pseudoptosis
• Microphthalmous
• Pthisis bulbi
• Double elevator
  palsy
• Blepharospasm
• Contralateral
  proptosis
• Enopthalmous
History
•   History of present illness
•   Associated history
•   Past history
•   Family history
History
•   History of present illness :age of onset
•   Associated history          duration
•   Past history                one/both eye
•   Family history              variability
                                vision
History
•   History of present illness
•   Associated history : diplopia
•   Past history          odynophagia
•   Family history        muscle weakness
                          cardiac problem
                          night blindness
History
•   History of present illness
•   Associated history
•   Past history : trauma/ surgery
•   Family history contact lens
                    lid edema
                    allergy
                    dry eyes
                    previous ptosis surgery
History
•   History of present illness
•   Associated history
•   Past history
•   Family history
evaluation of ptosis
• head posture,Eyebrow position, eyelid
  masses, inflammation, proptosis
• pupillary size, reaction, heterochromia
• Best corrected Visual Acuity: In
  infants, make sure infant can fix and
  follow light with each eye
• Cycloplegic Refraction
evaluation of ptosis
• Strabismus Evaluation
• Extraocular Muscles Motility: Note
  paresis, paralysis of muscles
• Bell’s phenomenon
• Jaw-Winking Phenomena Evaluation
• Corneal Sensitivity
• Schirmer’s Test
• Funduscopic Examination : Abnormal
  retinal pigmentation
Bell’s phenomenon
evaluation of ptosis
• Strabismus Evaluation
• Extraocular Muscles Motility: Note
  paresis, paralysis of muscles
• Bell’s phenomenon
• Jaw-Winking Phenomena
• Corneal Sensitivity
• Schirmer’s Test
• Funduscopic Examination : Abnormal
  retinal pigmentation
Marcus gunn jaw winking
     phenomenon
evaluation of ptosis
• Strabismus Evaluation
• Extraocular Muscles Motility: Note
  paresis, paralysis of muscles
• Bell’s phenomenon
• Jaw-Winking Phenomena
• Corneal Sensitivity
• Schirmer’s Test
• Funduscopic Examination : Abnormal
  retinal pigmentation
In children
• Presence or absence of Lid fold
• Head tilt
• Iliff test
Measurements
•   Vertical fissure height
•   Margin reflex distance
•   LPS action
•   Lid crease level
•   Lid level on down gaze
Vertical fissure height
• The distance between the upper and lower
  eyelid in vertical alignment with the center of
  the pupil in primary gaze, with the patient’s
  brow relaxed.
• Normal – 9-10mm in primary gaze
• Should be seen in up gaze, down gaze and
  primary gaze
• Amount of ptosis = difference in palpebral
  apertures in unilateral ptosis or Difference
  from normal in bilateral ptosis
Ptosis - Dr.Divya
Grading of severity of ptosis



    < or = 2mm : mild ptosis
    = 3 mm : moderate ptosis
    = or > 4 mm : severe ptosis
MRD
• Margin-to-reflex distance 1 (MRD1) : is the
  distance from the central pupillary light
  reflex to the upper eyelid margin with the eye
  in primary gaze.
• A measurement of 4 - 5 mm is considered
  normal.
• If the margin is above the light reflex the
  MRD 1 is a +ve value.
• If the lid margin is below the corneal reflex
  in cases of very severe ptosis the MRD 1
  would be a –ve value. 
Ptosis - Dr.Divya
MRD
• Margin-to-reflex distance 2 (MRD2) : is
  the distance from the central pupillary
  light reflex to the lower eyelid margin
  with the eye in primary gaze. . 
• The MRD1 plus the MRD2 should equal
  the palpebral fissure measurement
Levetor function
•  is the distance the eyelid travel from
  downgaze to upgaze while the frontalis muscle
  is held inactive at the brow.
• The normal levator function is between 13-
  17mm
• Lid excursion is a measure of the levator
  function. The frontalis action is blocked by
  keeping the thumb tightly over the upper
  brow and asking the patient to look up from
  down gaze and measuring the amount of upper
  lid excursion at the center of the lid.
Berkes method
Grading of levator action


 < 4mm – poor levator function
 5-7 mm – fair levator function
 8-12 mm – good levtor function
Lid crease
• Position is the distance from the crease to lid
  margin
• Normal – 8 to 10mm in primary gaze
• An absent lid crease is often accompanied by
  poor levator function.
• If a lid crease is present but is higher than
  normal and if a deeper upper lid sulcus is
  found on that side, note these as signs of a
  levator aponeurosis disinsertion.
Ptosis - Dr.Divya
Phenyl ephrine test
• Patients with minimal ptosis (2 mm or less) should
  have a phenylephrine test performed in the involved
  eye or eyes
•   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
Ice test
Investigation
•   Serum acetylcholine receptor assay
•   Tensilon test
•   EMG
•   ECG
•   ERG
•   T3, T4, TSH
Surgical management
• Wait till 3-4 years of age
• Pupil covered operate immeditely
Surgical management
Surgical management
Case 1
• A 25 year old man is seen in OPD 2 months
  after blunt trauma to right orbit. Examination
  is normal except for blepharoptosis in RE.
  Levator function is normal on bothsides and
  the patient states the eyelid positions were
  equal on both sides prior to injury. There is
  no enophthalmous, and the patient does not
  complain of diplopia.
Case 1
•   CT scan to rule out orbital fracture
•   Tensilon test to rule out myasthenia
•   Surgical exploration and repair of aponeurosis
•   Close observation
Case 2
        EYE VITALS         RE      LE

VERTICAL FISSURE           10      7.5

MRD 1                      +4     +1.5

LEVATOR FUNCTION           14      15

EYELID CREASE                 8    12

SCHRIMER’S                10mm    10mm
Case 2
•   Levator aponeurosis advancement
•   Blepharoplasty
•   Frontalis suspention
•   Levator muscle resection
Case 3
• A 10 year old girl has bulging and
  blepharoptosis of both upper eyelids and
  recurrent episodes of eyelid inflammation and
  swelling. The diagnosis is
• Dermatochalasis
• Blepharochalasis
• Steatoblepharon
• blepharospasm
Ptosis - Dr.Divya

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Ptosis - Dr.Divya

  • 2. Blepharoptosis • Greek word : to fall • Is abnormal infero displacement of upper eye lid
  • 4. classification Neurogenic Myogenic • Third nerve palsy • Myasthenia gravis • Horner’s syndrome • Myotonic dystrophy • OPMD • CPEO
  • 5. classification Aponeurotic Mechanical • Involutional • Tumor • Post operative • Dermatochalasis • Oedema • Scarring
  • 6. pseudoptosis • Microphthalmous • Pthisis bulbi • Double elevator palsy • Blepharospasm • Contralateral proptosis • Enopthalmous
  • 7. History • History of present illness • Associated history • Past history • Family history
  • 8. History • History of present illness :age of onset • Associated history duration • Past history one/both eye • Family history variability vision
  • 9. History • History of present illness • Associated history : diplopia • Past history odynophagia • Family history muscle weakness cardiac problem night blindness
  • 10. History • History of present illness • Associated history • Past history : trauma/ surgery • Family history contact lens lid edema allergy dry eyes previous ptosis surgery
  • 11. History • History of present illness • Associated history • Past history • Family history
  • 12. evaluation of ptosis • head posture,Eyebrow position, eyelid masses, inflammation, proptosis • pupillary size, reaction, heterochromia • Best corrected Visual Acuity: In infants, make sure infant can fix and follow light with each eye • Cycloplegic Refraction
  • 13. evaluation of ptosis • Strabismus Evaluation • Extraocular Muscles Motility: Note paresis, paralysis of muscles • Bell’s phenomenon • Jaw-Winking Phenomena Evaluation • Corneal Sensitivity • Schirmer’s Test • Funduscopic Examination : Abnormal retinal pigmentation
  • 15. evaluation of ptosis • Strabismus Evaluation • Extraocular Muscles Motility: Note paresis, paralysis of muscles • Bell’s phenomenon • Jaw-Winking Phenomena • Corneal Sensitivity • Schirmer’s Test • Funduscopic Examination : Abnormal retinal pigmentation
  • 16. Marcus gunn jaw winking phenomenon
  • 17. evaluation of ptosis • Strabismus Evaluation • Extraocular Muscles Motility: Note paresis, paralysis of muscles • Bell’s phenomenon • Jaw-Winking Phenomena • Corneal Sensitivity • Schirmer’s Test • Funduscopic Examination : Abnormal retinal pigmentation
  • 18. In children • Presence or absence of Lid fold • Head tilt • Iliff test
  • 19. Measurements • Vertical fissure height • Margin reflex distance • LPS action • Lid crease level • Lid level on down gaze
  • 20. Vertical fissure height • The distance between the upper and lower eyelid in vertical alignment with the center of the pupil in primary gaze, with the patient’s brow relaxed. • Normal – 9-10mm in primary gaze • Should be seen in up gaze, down gaze and primary gaze • Amount of ptosis = difference in palpebral apertures in unilateral ptosis or Difference from normal in bilateral ptosis
  • 22. Grading of severity of ptosis < or = 2mm : mild ptosis = 3 mm : moderate ptosis = or > 4 mm : severe ptosis
  • 23. MRD • Margin-to-reflex distance 1 (MRD1) : is the distance from the central pupillary light reflex to the upper eyelid margin with the eye in primary gaze. • A measurement of 4 - 5 mm is considered normal. • If the margin is above the light reflex the MRD 1 is a +ve value. • If the lid margin is below the corneal reflex in cases of very severe ptosis the MRD 1 would be a –ve value. 
  • 25. MRD • Margin-to-reflex distance 2 (MRD2) : is the distance from the central pupillary light reflex to the lower eyelid margin with the eye in primary gaze. .  • The MRD1 plus the MRD2 should equal the palpebral fissure measurement
  • 26. Levetor function •  is the distance the eyelid travel from downgaze to upgaze while the frontalis muscle is held inactive at the brow. • The normal levator function is between 13- 17mm
  • 27. • Lid excursion is a measure of the levator function. The frontalis action is blocked by keeping the thumb tightly over the upper brow and asking the patient to look up from down gaze and measuring the amount of upper lid excursion at the center of the lid.
  • 29. Grading of levator action < 4mm – poor levator function 5-7 mm – fair levator function 8-12 mm – good levtor function
  • 30. Lid crease • Position is the distance from the crease to lid margin • Normal – 8 to 10mm in primary gaze • An absent lid crease is often accompanied by poor levator function. • If a lid crease is present but is higher than normal and if a deeper upper lid sulcus is found on that side, note these as signs of a levator aponeurosis disinsertion.
  • 32. Phenyl ephrine test • Patients with minimal ptosis (2 mm or less) should have a phenylephrine test performed in the involved eye or eyes •   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
  • 34. Investigation • Serum acetylcholine receptor assay • Tensilon test • EMG • ECG • ERG • T3, T4, TSH
  • 35. Surgical management • Wait till 3-4 years of age • Pupil covered operate immeditely
  • 38. Case 1 • A 25 year old man is seen in OPD 2 months after blunt trauma to right orbit. Examination is normal except for blepharoptosis in RE. Levator function is normal on bothsides and the patient states the eyelid positions were equal on both sides prior to injury. There is no enophthalmous, and the patient does not complain of diplopia.
  • 39. Case 1 • CT scan to rule out orbital fracture • Tensilon test to rule out myasthenia • Surgical exploration and repair of aponeurosis • Close observation
  • 40. Case 2 EYE VITALS RE LE VERTICAL FISSURE 10 7.5 MRD 1 +4 +1.5 LEVATOR FUNCTION 14 15 EYELID CREASE 8 12 SCHRIMER’S 10mm 10mm
  • 41. Case 2 • Levator aponeurosis advancement • Blepharoplasty • Frontalis suspention • Levator muscle resection
  • 42. Case 3 • A 10 year old girl has bulging and blepharoptosis of both upper eyelids and recurrent episodes of eyelid inflammation and swelling. The diagnosis is • Dermatochalasis • Blepharochalasis • Steatoblepharon • blepharospasm