Ptosis
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PTOSIS Types,causes,examination,treatment
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Ptosis
- 3. DEFINITION Abnormal drooping of upper eyelid is called ptosis. Normally upper eyelid covers 1/6th of cornea i.e. 2mm. Therefore, in ptosis it covers >2mm
- 4. TYPES 1.CONGENITAL PTOSIS • Simple congenital ptosis • Blepharophimosis syndrome • Marcus Gunn jaw winking ptosis (congenital synkinetic ptosis)
- 5. Simple congenital ptosis • Developmental dystrophy of levator muscle • Occasionally associated with weakness of superior rectus Frequent absence of upper lid crease Usually poor levator function
- 6. 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) Poorly developed nasal bridge and hypoplasia of superior orbital rims
- 7. 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
- 8. 2.ACQUIRED PTOSIS •Neurogenic ptosis •Myogenic ptosis • Aponeurotic ptosis •Mechanical ptosis
- 9. Horner syndrome(neurogenic) • Caused by oculosympathetic palsy • Usually unilateral mild ptosis and miosis • Normal pupillary reactions ptosis (paralysis of Muller’s muscle)
- 10. third nerve palsy(neurogenic) Severe unilateral ptosis and defective adduction Defective elevation Normal abduction Defective depression
- 11. Ocular myasthenia(myogenic) Ptosis • • bilateral but asymmetrical Worse with fatigue and in upgaze Diplopia • Intermittent and usually vertical
- 12. Aponeurotic ptosis Weakness of levator aponeurosis • Causes - involutional, postoperative and blepharochalasis • Mild High upper lid crease Severe Deep sulcus
- 13. Mechanical ptosis Due to excessive weight on upper lid Causes Dermatochalasis Severe lid oedema Large tumours Anterior orbital lesions
- 14. EXAMINATION • EVALUATION Pseudoptosis Trueptosis • Measurement of degree of ptosis • Margin reflex distance (MRD) • Assessment of levator function • Special investigations (Tests)
- 15. Causes of pseudoptosis Lack of lid support Ipsilateral hypotropia Contralateral lid retraction Brow ptosis - excessive eyebrow skin Dermatochalasis - excessive eyelid skin
- 16. 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)
- 17. Edrophonium test (tensilon test) Before injection • Measure amount of ptosis or diplopia before injection Positive result Inject i.v. test dose of edrophonium • Inject remaining dose if no hypersensitivity MYASTHENIA GRAVIS(paradoxical reversal) •
- 18. TREATMENT Congenital ptosis- Almost always surgical treatment Acquired ptosis-Treat the underlying cause SURGERY 1.Fasanella servant operation 2.Levator resection 3.Frontalis sling operation
- 19. Fasanella-Servat procedure Indicated for mild ptosis(1.5-2mm) with good levator function .. Excision of upper border of tarsus, lower border of Muller muscle and overlying conjunctiva
- 20. Levator resection Indicated for any ptosis provided levator function is at least 5 mm Contraindicated in patients having severe ptosis with poor levator function Shortening of levator complex Amount determined by levator function and severity of ptosis
- 21. Frontalis brow suspension • • Main indications Severe ptosis with poor levator function ( 4 mm or less ) Marcus Gunn jaw-winking syndrome Attachment of tarsus to frontalis muscle with sling