Ptosis

Ptosis- causes and management

1. PTOSIS Dr. Christina Samuel Postgraduate Ophthalmology MMCH & RI

2. OBJECTIVES DEFINITION TYPES EXAMINATION TREATMENT

3. DEFINITION Abnormal drooping of upper eyelids is called ptosis Normally upper eyelid covers 1/6 th of cornea ie ,. 2mm Therefore in ptosis it covers more than 2mm

4. TYPES OF PTOSIS 1.CONGENITAL PTOSIS #simple congenital ptosis # blepharophimosis syndrome # marcus gunn jaw winking ptosis (congenital synkinetic ptosis ) 2.ACQUIRED PTOSIS # neurogenic ptosis # myogenic ptosis # aponeurotic ptosis #mechanical ptosis

5. CLASSIFICATION OF PTOSIS Third nerve palsy 1. Neurogenic Third nerve misdirection Horner syndrome Marcus Gunn jaw-winking syndrome Myasthenia gravis Myotonic dystrophy Ocular myopathies Simple congenital 2. Myogenic 3. Aponeurotic 4. Mechanical Blepharophimosis syndrome

6. Simple congenital ptosis Developmental dystrophy of levator muscle Occasionally associated with weakness of superior rectus Unilateral or bilateral ptosis of varying severity In downgaze ptotic eyelid is slightly higher Frequent absence of upper lid crease Usually poor levator function

7. 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

8. 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

9. Left third nerve palsy Severe unilateral ptosis and defective adduction Normal abduction Defective elevation Defective depression

10. Bell’s phenomenon Upward rotation of globe on lid closure Good Poor - risk of postoperative corneal exposure

11. 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

12. Horner syndrome Caused by oculosympathetic palsy Usually unilateral mild ptosis and miosis Slight elevation of lower lid Normal pupillary reactions Iris hypochromia if congenital or longstanding Anhydrosis if lesion is below superior cervical ganglion

13. Important causes of Horner syndrome Central (first order neurone ) Brainstem disease (vascular, demyelination ) Spinal cord disease (syringomyelia, tumours) Pre- ganglionic (second order neurone ) Intrathoracic lesions (Pancoast tumour, aneurysm) Neck lesions (glands, trauma) Post- ganglionic (third order neurone ) Internal carotid artery disease Cavernous sinus mass Posterior hypothalamus Ciliospinal centre of Budge( C8 - T2 ) Superior cervical ganglion

14. Myasthenia Gravis Uncommon, typically affects young women 1 Clinical features . Edrophonium (Camiston) test 2. Investigations Medical - anticholinesterases, steroids and azathioprine 3. Treatment options Weakness and fatiguability of voluntary musculature Three types - ocular, bulbar and generalized Antibodies to acetylcholine receptors CT or MRI for presence of thymoma Electromyography to confirm fatigue Thymectomy

15. Ocular myasthenia Insidious, bilateral but asymmetrical Worse with fatigue and in upgaze Ptosis Ptotic lid may show ‘twitch’ and ‘hop’ signs Intermittent and usually vertical Diplopia

16. Myotonic dystrophy Facial weakness and ptosis Involvement of tongue and pharyngeal muscles Ophthalmoplegia - uncommon Muscle wasting Hypogonadism Frontal baldness in males Intellectual deterioration Presenile stellate cataracts Release of grip difficult

17. Ocular myopathies Isolated Oculopharyngeal dystrophy Kearns-Sayre syndrome (pigmentary retinopathy) Ptosis - slowly progressive and symmetrical Ophthalmoplegia - slowly progressive and symmetrical (no diplopia) Clinical types Ocular features

18. Aponeurotic ptosis Weakness of levator aponeurosis Causes - involutional, postoperative and blepharochalasis High upper lid crease Good levator function Absent upper lid crease Deep sulcus Mild Severe

19. Mechanical ptosis Causes Dermatochalasis Large tumours Severe lid oedema Anterior orbital lesions

20. Causes of pseudoptosis Ipsilateral hypotropia Brow ptosis - excessive eyebrow skin Dermatochalasis - excessive eyelid skin Lack of lid support Contralateral lid retraction

21. 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)

22. Reflects levator function Normal (15 mm or more) Good (12 mm or more) Fair (5-11 mm) Upper lid excursion Poor (4 mm or less)

23. 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 Vertical fissure height

24. Upper lid 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 Pretarsal show crease fold

25. Edrophonium test 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 Before injection Positive result

26. Fasanella-Servat procedure Excision of upper border of tarsus, lower border of Muller muscle and overlying conjunctiva Indicated for mild ptosis with good levator function ..

27. Levator resection Shortening of levator complex Indicated for any ptosis provided levator function is at least 5 mm Amount determined by levator function and severity of ptosis

28. Frontalis brow suspension Attachment of tarsus to frontalis muscle with sling Main indications Severe ptosis with poor levator function ( 4 mm or less ) Marcus Gunn jaw-winking syndrome

29. THANK U