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  2. PTOSIS Definition Abnormal low position of upper lid. May be Congenital or Acquired
  3. CAUSES 1. Neurogenic  Caused by an innervational defect e.g.  3rd Nerve paresis.  Horners Syndrome (oculosympathetic palsy). 2. Myogenic  Caused by myopathy of levator muscle it self  Impairment of impulses at neuromuscular junction(Neuromyopathic cause). NOTE  Acquired myogenic Ptosis occurs in  Myasthenia gravis  Myotonic Dystrophy  Progressive External Ophthamoplegia
  4. CAUSES Cont”d 3. Aponeurotic Caused by defect in levator aponeurosis. 4. Mechanical May occur due to the following.  Scarring.  Gravitational effect of a mass.
  5. CLINICAL EVALUATION OF PTOSIS 1. History Age at onset of ptosis. Duration of ptosis If history is not clear, check old photos. Ask about symptoms of possible underlying systemic disease e.g.  Associated diplopia.  Variability of Ptosis during the day and in presence of excessive fatigue.
  6. PSEUDO PTOSIS  Rule out possible causes of pseudo ptosis. a) Lack of support of the lids by the globe leads to orbital volume deficit. Found in following conditions  Artificial eye  Microphthalmos  Phthisis bulbi.  Enophthalmos b) Contralateral Lid Retraction  Compare the levels of upper lid margins. NOTE  Normal upper lid margin covers 2mm of superior cornea c) Ipsilateral Hypotropia  Causes pseudoptosis because upper lid follows the globe in down gaze
  7. Pseudoptosis Rt Phthisis bulbi
  8. PSEUDOPTOSIS –Cont”d d) Brow Ptosis  Due to excessive skin on the brow or 7th nerve palsy. e) Dermatochalasis  Excessive skin on upper lid.
  9. Pseudoptosis Contralateral lid retraction
  10. Pseudoptosis - Ipsilateral Hypotropia
  11. Pseudoptosis bilateral brow ptosis
  12. PTOSIS MEASUREMENTS 1 Margin-Reflex distance (MRD)  Distance between the upper lid margin and corneal reflection of pen torch held by examiner. Normal 4-4.5mm 2. Palpebral Fissure Height  Distance between upper and lower lid margins. Normal Males 7-10mm Females 8-12mm Ptosis Grade 2mm-mild 3mm-moderate 4mm-severe
  13. Margin reflex distance
  14. Palpebral fissure height
  15. MEASUREMENTS Cont”d 3. Levator Function (Upper lid excursion)  Place thumb firmly against patients brow to negate action of frontalis muscle with eyes in down gaze.  Patient then looks up as far as possible.  Amount of excursion is measured with a rule. Normal-up to 15mm Good 12-14mm Fair 5-11mm Poor 4mm or less
  16. Levator function
  17. MEASUREMENT Cont”d 4. Upper Lid Crease  Vertical distance between the lid margin and lid crease in down gaze. Normal Female-10mm Male 8mm. NOTE  Absence of crease in a case of congenital Ptosis suggests poor levator function.  High crease suggests an aponeurotic defect. 5 Pretarsal show.  Distance between the lid margin and skin with eyes in primary position
  18. ASSOCIATED SIGNS cont”d 4. Jaw- winking Phenomenon  Ask patient to chew and move the jaws from side to side. 5. Bells Phenomenon  Manually hold the lid open, asking the patient to try to shut his eyes and observe upward and outward rotation of the globe. NOTE  Weak Bells Phenomenon has risk of post operative exposure keratitis.
  19. Jaw-winking 1
  20. Jaw winking 2
  21. TYPES OF PTOSIS 1. Simple Congenital Ptosis a) Pathogenesis  Failure of nerve migration or development with muscular sequelae b) Signs  Unilateral or bilateral ptosis of variable severity  Absent upper lid crease  In down gaze the ptotic lid is higher than the normal because of poor relaxation of levator.
  22. Congenital Mild Right Ptosis
  23. Congenital severe left ptosis
  24. Congenital severe bilateral ptosis
  25. OTHER ASSOCIATIONS  Superior rectus weakness may be present. Compensatory chin elevation, especially in bilateral cases. Refractive errors are common. TREATMENT a. Levator resection. b. Should be done during pre school years.
  26. 2. MARCUS GUN JAW_WINKING SYNDROME  About 5% of all cases of Congenital Ptosis manifest Marcus Gun Jaw-winking phenomenon  Postulated that a branch of the mandibular division of 5th cranial nerve is misdirected to the levator muscle. SIGNS  Retraction of the Ptotic lid in conjunction with stimulation of the ipsilateral pterygoid muscle by chewing, sucking, opening mouth or jaw movement.  Jaw winking does not improve with age.
  27. SURGERY Possible procedures which can improve cosmesis.  Unilateral levator resection.  Unilateral levator disinsertion.  Bilateral levator disinsertion
  28. 3rd NERVE MISDIRECTION SYNDROME Misdirection syndrome may be congenital or acquired,or follow acquired 3rd nerve palsies. SIGNS Bizare movements of the upper lid which accompany various eye movements. TREATMENT Levator disinsertion and brow suspension
  29. 3rd Nerve misdirection syndrome
  30. INVOLUTIONAL PTOSIS  Age- related condition caused by dehiscence, disinsertion or stretching of the levator aponeurosis.  This restricts transmission of force from a normal levator muscle to the upper lid. SIGNS  Variable bilateral ptosis.  High upper lid crease.  In severe cases upper lid crease may be absent. TREATMENT  Options include.  Levator resection ,advancement with re insertion.
  31. Involutional ptosis
  32. MECHANICAL PTOSIS Result of impaired mobility of the upper lid. May be caused by large tumours, heavy scar tissue, severe oedema and anterior orbital lesions.
  33. Mechanical ptosis neurofibroma
  34. PTOSIS SURGERY OPTIONS 1 CONJUNCTIVA-MULLER RESECTION Indications  Mild Ptosis with Levator Function of at least 10mm  Maximum lift of the lid is 2-3mm.  Useful in mild Congenital Ptosis and Horners Syndrome.
  35. 2. LEVATOR RESECTION Indications  Any cause provided Levator function is at least 5mm. Technique  Involves shortening of Levator Complex through either skin or posterior conjuctiva approach.
  36. Conjuctiva-muller resection
  37. SURGRY OPTIONS Cont”d 3. BROW SUSPENSION Indications  Severe Ptosis (over 4mm) with poor levator function.  Marcus Gun jaw-winking syndrome  Ptosis associated with aberrant regeneration of 3rd nerve.  Unsatisfactory result from previous levator resection SURGERY  Involves suspension of the tarsus from the frontalis muscle with a sling of fascia lata or non absorbable material such as prolene or silicone.
  38. Brow suspension