Ptosis

This presentation discuss all aspects of Ptosis as regards; causes, diagnosis and treatment.

1. Ptosis By Dr. Amr Mounir Lecturer of Ophthalmology Sohag University

2. Definition: It is drooping of the upper eyelid due to paralysis or disease, or due to a congenital condition.

3. Etiology Myogenic Neurogenic Aponeurotic Mechanical

4. Myogenic ptosis A)Congenital ptosis: due to dystrophy of levator muscle lead to poor contraction and incomplete relaxation

5. B) Acquired ptosis (Myasthenia gravis) : due to defect in the myoneural junction.. it is progressive at the end of the day and on prolonged fixation

6. Neurogenic ptosis Third nerve palsy : paralytic ptosis (Diabetes- congenital-traumatic) Horner’s syndrome : due to interference with sympathetic nerve supply with characteristic ptosis, miosis, anhidrosis and enophthalmos

7. Aponeurotic ptosis (disorder in levator aponeurosis) Senile (involutional): degenerative changes with age Postoperative ptosis: following cataract surgery and retinal detachment surgery ( damage of levator ,superior rectus comlex )

8. Mechanical ptosis Excess eyelid weight ( edema-tumor- chalizion )

9. Degree of ptosis 1- Assessment of ptosis: Degree of ptosis (Margin-reflex-distance):normal (4-4.5mm) Mild 2mm dropping Moderate 3mm dropping Severe 4-4.5mm dropping

10. 2- Levator function tests: 1-Distance of U.L : movement from down gaze to up gaze(upper lid excursion) 2-Upper lid crease presence 15 mm Normal 5-11mm Fair 12-15mm Good 5mm Poor

11. 3)Associated signs: Marcus-Gunn (jaw-winking) phenomenon: Ocular motility Bell’s phenomenon Corneal sensation Squint Increased innervation Pupil: ptosis &mydriasis>>third nerve palsy Ptosis &miosis>> horner’s syndrome

12. Marcus-Gunn (jaw – winking) phenomenon

13. Bell’s phenomenon

14. Corneal sensations

15. The Effect of Hering's Law in Ptosis with increased innervation

16. Pupil Appearance 3 rd nerve Palsy Horners Synrome

17. Differential diagnosis Causes of pseudo-ptosis Contralateral side Ipsilateral side Lid retraction Severe proptosis Lack of support Hypotropia Excessive dermatochalesis

18. Treatment Aim of surgery: 1) Maintenance of correct eyelid position 2) Preservation of the normal eyelid crease 3) Maintenance of the normal tear film 4) Prevention of exposure keratopathy by prevention of over correction.

19. Frontalis sling Involves creation of a linkage between the frontalis muscle and the tarsal and epitarsal tissue of the upper eyelid. This allows eyelid elevation to be performed through the use of the frontalis muscle, thereby bypassing a poorly functioning levator .

20. Indicated in congenital ptosis and poor levator function or congenital Marcus Gunn jaw wink phenomenon. Disadvantages of this procedure include the risk of lagophthalmos and eyelid lag in down gaze, scarring in young children, loss of the eyelid crease, and The recurrence rate of ptosis after 20 months postoperatively is 26%

21. Levator resection and advancement Patients with greater than 5 mm of levator function. Advantages: it preserves normal anatomical planes and structures of the eyelid.

22. WHITNALL SLING Indicated in severe ptosis with levator function of 3–5 mm. This procedure involves resecting the levator aponeurosis up to the point of Whitnall's ligament, and then suturing both Whitnall's ligament and the underlying levator muscle to the superior portion of the tarsal plate.

23. MULLERECTOMY The Muller's muscle is an involuntary, sympathetically innervated muscle that originates below the levator aponeurosis. It is indicated for patients who respond well to the phenylephrine test, thereby shortening Muller's muscle.

24. Thank You