CLASSIFICATION OF PTOSIS

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CLASSIFICATION OF PTOSIS
1. Neurogenic

• Third nerve palsy

• Third nerve misdirection

• Horner syndrome

• Marcus Gunn jaw-winking syndrome

2. Myogenic

• Myasthenia gravis

• Myotonic dystrophy

• Ocular myopathies

• Simple congenital

• Blepharophimosis syndrome

3. Aponeurotic
4. Mechanical
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PTOSIS
1. Evaluation

• Pseudoptosis
• True ptosis

2. Classification

• Neurogenic ptosis

• Myogenic ptosis

• Aponeurotic ptosis

• Mechanical ptosis

3. Treatment options
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Causes of pseudoptosis
Contralateral lid retraction
Lack of lid support
Ipsilateral hypotropia
Brow ptosis - excessive eyebrow skin
Dermatochalasis - excessive eyelid skin
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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)

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Upper lid excursion

• Reflects levator function

• Normal (15 mm or more)

• Good (12 mm or more)

• Fair (5-11 mm)

• Poor (4 mm or less)

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Vertical fissure height

• 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

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Upper lid crease
Pretarsal show
fold
crease

• Distance between lash line and skin fold
• in primary position of gaze

• 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

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Bells phenomenon
Upward rotation of globe on lid closure
Good
Poor - risk of postoperative corneal exposure
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Left third nerve palsy
Severe unilateral ptosis and
Normal abduction
defective adduction
Defective elevation
Defective depression
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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
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Horner syndrome

• Caused by oculosympathetic
• palsy

• Usually unilateral mild
• ptosis and miosis

• Normal pupillary reactions

• Slight elevation of lower lid

• Iris hypochromia if
• congenital or longstanding

• Anhydrosis if lesion is below
• superior cervical ganglion

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Important causes of Horner syndrome
Central (first order neurone)
Posterior hypothalamus

• Brainstem disease
• (vascular, demyelination)

• Spinal cord disease
• (syringomyelia, tumours)

Pre-ganglionic (second order neurone)
Superior cervical ganglion

• Intrathoracic lesions
• (Pancoast tumour, aneurysm)

• Neck lesions
• (glands, trauma)

Post-ganglionic (third order neurone)

• Internal carotid artery disease

Ciliospinal centre of Budge( C8 - T2 )

• Cavernous sinus mass

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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

Contralateral movement of jaw
Opening of mouth
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Myasthenia Gravis
1. Clinical features

• Uncommon, typically affects young women

• Weakness and fatiguability of voluntary
  musculature

• Three types - ocular, bulbar and generalized

2. Investigations

• Edrophonium (Camiston) test

• Electromyography to confirm fatigue

• Antibodies to acetylcholine receptors

• CT or MRI for presence of thymoma

3. Treatment options

• Medical - anticholinesterases, steroids and
  azathioprine

• Thymectomy

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Ocular myasthenia
Ptosis
Diplopia

• Insidious, bilateral but asymmetrical

• Intermittent and usually vertical

• Worse with fatigue and in upgaze

• Ptotic lid may show twitch and
• hop signs

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Edrophonium test
Before injection
Positive result

• Measure amount of ptosis or
• diplopia before injection

• Inject i.v. test dose of edrophonium
• (0.2 ml-2 mg)

• Inject remaining (0.8 ml-8 mg) if no
• hypersensitivity

• Inject i.v. atropine 0.3 mg

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Myotonic dystrophy
Facial weakness and ptosis
Release of grip difficult

• Muscle wasting

• Hypogonadism

• Frontal baldness in males

• Involvement of tongue and pharyngeal muscles

• Intellectual deterioration

• Ophthalmoplegia - uncommon

• Presenile stellate cataracts

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Ocular myopathies
Ocular features
Clinical types

• Isolated

• Ptosis - slowly progressive and
• symmetrical

• Oculopharyngeal dystrophy

• Ophthalmoplegia - slowly
• progressive and symmetrical
• (no diplopia)

• Kearns-Sayre syndrome
• (pigmentary retinopathy)

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Simple congenital ptosis

• Developmental dystrophy of levator muscle

• Occasionally associated with weakness of
  superior rectus

In downgaze ptotic eyelid is slightly higher
Unilateral or bilateral ptosis of varying
severity
Frequent absence of upper lid crease
Usually poor levator function
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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

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Aponeurotic ptosis

• Weakness of levator aponeurosis

• Causes - involutional, postoperative and
  blepharochalasis

Mild
High upper lid crease
Good levator function
Severe
Absent upper lid crease
Deep sulcus
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Mechanical ptosis
Causes
Dermatochalasis
Large tumours
Severe lid oedema
Anterior orbital lesions
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Fasanella-Servat procedure
Indicated for mild ptosis with good levator
function
..
Excision of upper border of tarsus, lower
border of Muller muscle and overlying
conjunctiva
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Levator resection
Indicated for any ptosis provided levator
function is at least 5 mm
Shortening of levator complex
Amount determined by levator function and
severity of ptosis
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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