Ptosis

how to evaluate ptosis

1. PTOSIS HOW TO EVALUATE ITS CLINICAL ASPECT Dr. Neeraj Agarwal GMC, KOTA

2. Blepharoptosis is derived from the greek word blepharon =eyelid and ptosis= falling. So blepharoptosis means drooping of upper eyelid. Blepharoptosis often abbreviated as ptosis. Normally upper eyelid covers 1/6 th of cornea i.e. 2mm Therefore in ptosis it covers more than 2mm .

3. CLASSIFICATION CONGENITAL ACQUIRED

4. CONGENITAL Simple ptosis With SR weakness With blepharophimosis syndrome Synkinetic ptosis – Marcus Gun Jaw Winking ptosis, Misdirected third nerve syndrome

5. ACQUIRED PTOSIS Neurogenic - 3 rd nerve palsy, horner syndrome. Myogenic - myasthenia gravis, Myotonic dystrophy. Aponeurotic- involutional , post surgical Mechanical- tumour, swelling.

6. P seudoptosis Ipsilateral hypotropia Enopthalmos Dermatochalasis Double elevator palsy Brow ptosis Blepharospasm Contralateral lid retraction Contralateral exopthalmos

7. EVALUATION OF PTOSIS When patient enters examination room, observation of the head posture with chin elevation and frontalis overaction indicate severe ptosis.

8. HISTORY Age of onset Duration Unilateral/bilateral Weather ptosis worsen through the day Diplopia Muscle weakness trauma/ surgery lid edema previous ptosis surgery

9. Presence of any aberrant lid movements Weather eye movements are impaired Past medical history Current medications Family history Old photographs

10. EXAMINATION Head posture Periocular fullness Frontalis overaction Scar mark Lid skin laxity Telecanthus , epicanthus inversus

11. Ocular Motility:  Importance in myogenic ptosis, To R/O 3 rd nerve palsy presence of strabismus, especially vertical strabismus entails that it be corrected prior to the correction of the ptosis. Visual acuity  Best-corrected visual acuity should be assessed to record any amblyopia if present, especially in cases of congenital ptosis

12. Refraction- Cycloplegic test refraction is indicated in all children with ptosis since it is known that a significant number have anisometropia primarily due to astigmatism on the ptotic side. Any significant refractive error should be corrected

13. MEASUREMENTS Margin reflex distance 1(MRD 1)- After shining the torchlight in the patient eye, the distance between the corneal light reflex to the centre of the upper lid margin is measured . Normal value is 4- 4.5mm.

14. 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)

15. Margin reflex distance 2 (MRD 2)- the distance of corneal light reflex to the centre of the lower eyelid margin in primary gaze. Normal value is 5- 5.5mm

16. Margin reflex distance 3(MRD 3)- the distance between the corneal light reflex and the centre of upper eyelid margin in extreme upgaze.

17. Palpebral fissure height (PFH)- MRD1 + MRD2. Central palpebral fissure height is measured in primary gaze and compared with the normal eye in unilateral ptosis.

18. Also it is important to measure the PFH in downgaze. As reduced ptosis/ lid lag is seen in congenital ptosis as the dystrophic muscle neither contracts nor relaxes.

19. Upgaze accentuate ptosis Downgaze  lid lag

20. Margin crease distance(MCD)- it is an important anatomical landmark, which give clue to levator action. It is measured with patient looking down, distance from the central eyelid margin to the most prominent lid crease. Normal value in Men 5-7mm, women 8-10mm Crease is absent in congenital ptosis and higher in aponeurotic ptosis.

21. An absent lid crease is often accompanied by poor levator function. If a lid crease is present, but higher than normal and if there is a deeper upper lid sulcus on that side these should be noted as signs of levator disinsertion .

22. MARGIN LIMBAL DISTANCE- it gives the degree of loss of Levator action. It is measured as the distance between the centre of upper lid margin to 6o’clock limbus in extreme upgaze Normally it is 9mm .

23. Levator function test- E xcursion of upper eyelid from extreme downgaze to extreme upgaze is a measure of LPS function, negating the action of frontalis muscle ( Berke’s method ).

24. Grading of levator function- >15mm= normal >8 mm= good 5-7 mm= fair <4 mm= poor

25. ILLIF’s test Used in children Pt upper lid is everted in downgaze. On looking up, the lid should return to normal position if levator action is good.

26. Marcus gunn jaw winking phenomenon Marcus Gunn jaw-winking phenomenon is the most common form of congenital synkinetic neurogenic ptosis. The unilaterally ptotic eyelid elevates with jaw movements due to cross innervations between oculomotor nerve and mandibular branch of trigeminal nerve This synkinesis is best demonstrated by having the patient move the jaw the opposite side. The internal pterygoid may be involved, but rarely.

27. Grading of marcus gunn phenomenon Mild- maximum elevation of ptotic eyelid non- ptotic position Moderate- maximum elevation goes upto superior limbus Severe- maximum elevation beyond the superior limbus with scleral show

28. BELL’S PHENOMENON- the eyes moves generally upwards and outwards on eyelid closure. It is extremely important in assessing post-operative corneal complications. Poor bells phenomenon invariably warrants under correction.

29. BELLS PHENOMENON GRADING- good= >2/3 of cornea disappears fair= 1/3 – 2/3 of cornea disappears poor= <1/3 of cornea disappears VARIANT- Inverse- upward & inward Reverse- downward & outward Preverse - different directions

30. BELLS PHENOMENON

31. Corneal sensation- always check before planning the surgery. Schirmers test – to rule out dry eye disease Pupillary abnormalities- miosis in horner’s syndrome mydriasis in 3 rd nerve palsy.

32. Look for any associated mass lesion causing mechanical ptosis

33. Cogan's lid twitch sign-  may be seen when the patient first looks down for a short period and then look back to primary position. The upper eyelid elevates excessively during this upward movement. This is interpreted as transient improvement in lid strength after rest of the levator in downgaze, followed by droop in the primary position as the levator fatigues

34. Phenylephrine test- The function of muller’s is tested by applying drops of 10% phenylephrine to the eye on the side of blepharoptosis . A rise in the MRDl of 1.5 mm or greater is considered a positive test.  This indicates that Müller's muscle is viable . so operation to resect muller’s muscle and conjunctiva can relieve blepharoptosis .

35. Edrophonium test Measure amount of ptosis or diplopia before injection Inject i.v . atropine 0.5 mg Inject i.v . test dose of edrophonium ( 0.2 ml-2 mg) inject remaining (0.8 ml-8mg ) if no hypersensitivity Before injection Positive result

36. ICE TEST  An ice pack is applied to the affected upper eyelid for 5 minutes. A positive test is the improvement of ptosis by > 2mm or more. This transient improvement in ptosis is due to the cold decreasing the acetylcholinesterase break-down of acetylcholine at the neuromuscular junction. More acetylcholine collects in the junction and therefore increases the muscle contraction.

37. Ice test

38. Photographic documentation- it is the most important aspect of ptosis evaluation. Review of old photographs gives clue to the duration and nature of ptosis.

39. So we should examine case of ptosis carefully before proceeding for surgical management, to avoid any post operative surprise.

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