PTOSIS

PTOSIS

PTOSIS

One can, however, be born with ptosis. Congenital ptosis is hereditary in three main forms. Causes of congenital
ptosis remain unknown. Ptosis may be caused by damage/trauma to the muscle which raises the eyelid, damage to
the superior cervical sympathetic ganglion or damage to the nerve which controls this muscle.

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

PTOSIS
1. Evaluation

Pseudoptosis
True ptosis

2. Classification
Neurogenic ptosis
Myogenic ptosis
Aponeurotic ptosis
Mechanical ptosis

3. Treatment options

Causes of pseudoptosis

Lack of lid support

Ipsilateral hypotropia

Contralateral lid retraction

Brow ptosis - excessive

eyebrow skin

Dermatochalasis - excessive
eyelid skin

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)

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)

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

Upper lid crease

Pretarsal show
fold

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

Bells 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

Defective elevation

Normal abduction

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

Normal pupillary reactions

Slight elevation of lower lid

Iris hypochromia if
congenital or longstanding

Anhydrosis if lesion is below

superior cervical ganglion

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

Ciliospinal centre of
Budge( C8 - T2 )

Intrathoracic lesions
(Pancoast tumour, aneurysm)
Neck lesions
(glands, trauma)

Post-ganglionic
(third order neurone)

Internal carotid artery disease

Cavernous sinus mass

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
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

Ocular myasthenia
Ptosis

Insidious, bilateral but asymmetrical

Worse with fatigue and in upgaze
Ptotic lid may show twitch and
hop signs

Diplopia

Intermittent and usually vertical

Edrophonium test
Before injection

Positive result

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

Myotonic dystrophy
Facial weakness and
ptosis

Release of grip difficult

Muscle wasting

Involvement of tongue and pharyngeal muscles

Ophthalmoplegia - uncommon

Hypogonadism
Frontal baldness in males
Intellectual deterioration
Presenile stellate cataracts

Ocular myopathies

Ocular features

Clinical types

Isolated

Oculopharyngeal dystrophy

Kearns-Sayre syndrome
(pigmentary retinopathy)

Ptosis - slowly progressive and

symmetrical
Ophthalmoplegia - slowly
progressive and symmetrical
(no diplopia)

Simple congenital ptosis

Developmental dystrophy of levator muscle

Occasionally associated with weakness of superior rectus

Unilateral or bilateral ptosis of varying

severity

Frequent absence of upper lid crease

In downgaze ptotic eyelid is slightly

higher

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

Mild

High upper lid crease

Good levator function

Severe

Absent upper lid crease

Deep sulcus

Mechanical ptosis
Causes

Dermatochalasis

Severe lid oedema

Large tumours

Anterior orbital lesions

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

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

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