PTOSIS OF UPPER LID AND MANAGEMENT OF PTOSIS

PTosis is down word displacement of upper lid
It can be due to senile conditions , mechanical conditions

1. PTOSIS
Presenter : Dr K Amulya Reddy
( 1st year PG )

2. Definition : Drooping of one/both upper eyelids

NORMAL Position of eyelids :
➢In the primary gaze Upper Lid covers 1/6th of the cornea
➢The Lower Lid just touches the inferior limbus
➢When the lid covers >2mm of cornea → Ptosis

3. ➢Muscles responsible - LPS and Muller’s Muscle
➢LEVATOR PALPEBRAE SUPERIORIS :
-Origin : Lesser wing of sphenoid near the apex of the orbit
-Insertion : a) Superior Fibres - Skin of eyelid → forms the Creases
- b) Deep Fibres - Anterior surface of the tarsus
-The distance from the insertion of LPS to the upper border of tarsus
= 3-4 mm
- Action : Elevation of the upper lid upto 15mm
-Nerve Supply : Occulomotor Nerve

4. ➢MULLER’s MUSCLE :
-Origin : Lower end of LPS
-Insertion : Attached to upper end of tarsus
-Action : Elevation of eyelid - upto 2mm
-Nerve Supply : Sympathetic supply

6. CLASSIFICATION :
1)CONGENITAL :

a)Congenital SIMPLE Ptosis :
-Due to the dystrophy of the LPS muscle
-Absence of Lid Crease
-Lid Lag : LPS doesn’t relax on downgaze
-Compensatory chin elevation
-Associated with Amblyopia

7. b) CONGENITAL COMPLICATED PTOSIS :
-Congenital Third Nerve Palsy
-Blepharophimosis
-Double Elevator Palsy ( associated with Superior Rectus palsy )
-Marcus Gunn Jaw Winking Phenomenon
-Synkinetic
-Congenital Aponeurotic Ptosis

8. 2) ACQUIRED PTOSIS :
NEUROGENIC a)Third Nerve Palsy
b)Horner’s Syndrome
MYOGENIC a)Myasthenia Gravis
b)Myotonic Dystrophy
c)Progressive External
Ophthalmoplegia
MECHANICAL Eyelid Tumors / Edema
APONEUROTIC Associated with Old Age
TRAUMATIC

9. CLINICAL EXAMINATION :
HISTORY :
➢Onset - Congenital / Acquired
➢Duration - Sudden / Gradual
➢Progression - Any Improvement
-Slow : Aponeurotic , Myogenic
-Sudden onset : Neurogenic
➢Unilateral or Bilateral
➢Associated with
-Visual loss
-Variability ( Myasthenia Gravis , Synkinesis , Aberrant Regeneration of IIIrd
nerve palsy )
-Head Postures : Chin lift ( Congenital Ptosis )

10. ➢Past History of Surgeries
-Iridectomy
-IOL Decentration during cataract surgeries
-Glaucoma Filtration Surgeries
➢Drug History : TOPICAL STEROIDS
➢Family History : In congenital cases ( blepharophimosis )
➢Old Photographs - to know the progression / improvement

CLINICAL EXAMINATION :

12. OCULAR EXAMINATION :
1)VISUAL ACUITY :
-In Congenital Ptosis - decreased due to Amblyopia
2)HEAD POSTURE :
-Congenital Ptosis - Chin Elevation
3)EYE POSITION and Extra Ocular Movements :
-Third Nerve Palsy
-Double Elevator Palsy
-Strabismus

13. 4) PUPIL :
-Mydriasis - Third nerve palsy
-Miosis - Horner’s Syndrome
5) Rule out PseudoPtosis :
-I/L Enophthalmia , Microphthalmos , Phthisis Bulbi
-I/L Hypotropia
-I/L Dermatochalasis , Blepharochalasis , Brow Ptosis
-C/L Lid Retraction , Proptosis , Buphthalmos
OCULAR EXAMINATION :

15. a)PALPEBRAL FISSURE HEIGHT :
➢Distance between Upper and Lower lid margin in the MidPupillary
plane measured in the Primary Gaze
➢Normal : 8-11mm

16. ➢Congenital Ptosis : Lid Lag
-The PALPEBRAL APERTURE IN DOWNGAZE is Wider in the ptotic eye except
in Congenital Aponeurotic ptosis

➢Aponeurotic Ptosis :
-The Palpebral APERTURE IN DOWNGAZE is Smaller than the normal eye

➢In Congenital and Acquired ptosis - difference in the level of eyelids is
maximal on upgaze
a)PALPEBRAL FISSURE HEIGHT :

18. b) MARGINAL REFLEX DISTANCE ( MRD1 & 2 )
➢Distance between the eyelid margin and the corneal reflex in
MidPupillary plane in Primary gaze - MRD

MRD1 = Upper Lid margin MRD 2 = Lower Lid margin
Normal : 4 - 5 mm Normal : 5 - 5.5 mm
➢MRD 3 : In extreme up gaze the distance between the corneal reflex
and the centre of the upper lid margin

19. Severity of
Ptosis
MRD 1
Mild 1-2mm
Moderate 2-3mm
Severe >/=4mm
→ MRD 3

20. c) MARGINAL FOLD & CREASE DISTANCE :
➢MARGINAL FOLD DISTANCE :
-Distance between upper eyelid crease and lid margin in Primary
Gaze
➢MARGINAL CREASE DISTANCE :
-Same measurement in Downgaze
-To plan the positioning of lid crease during Skin
approach Levator Resection Surgery

21. d) AMOUNT OF PTOSIS :
➢In UNILATERAL PTOSIS :
-PF normal - PF ptotic eye
-MRD1 normal - MRD2 ptotic eye
➢In BILATERAL PTOSIS :
-Compare with the Normal , Minus the value from 2mm ( which is the
normal covering of eyelid )

22. ➢GRADING :


➢If Upper lid covers >6mm or 1/6th - corneal light reflex cannot be
seen = NEGATIVE MRD
-Elevate the lid manually to see reflex and mark the point of the
Corneal reflex
-The amount of lid that needs to be lifted is noted as Negative MRD
MILD </= 2mm
MODERATE 3mm
SEVERE >/= 4mm
d) AMOUNT OF PTOSIS :

23. e) LEVATOR FUNCTION :
➢BERKE’s METHOD -
➔Block Frontalis muscle while the patient looks down → ask the
patient to look up
➔Maximum excursion of the eyelid from extreme downgaze to
extreme upgaze with frontalis negated is the Levator Action

➔Normal : >15mm

24. EXCELLENT 13-15mm
GOOD 8-12mm
FAIR 5-7mm
POOR </= 4mm

25. ➢OTHER : PUTTERMAN METHOD
-In Up Gaze → Distance from the upper lid margin to 6 o’ clock limbus


➢Child : ILLIF’s SIGN - Lid everted by the examiner does not flip back
to its Normal position
e) LEVATOR FUNCTION :

26. → PUTTERMAN’s METHOD
ILLIF’s SIGN ←

27. f) TARSAL PLATE SHOW :
➢Amount of tarsal plate visible between upper eyelid margin and lid
fold in Primary gaze

28. g) BROW HEIGHT :
➢Distance between the central corneal reflex to the lowest edge of
hair bearing part of brow

29. h) ANTERIOR LAMELLAR HEIGHT :
➢Vertical length of anterior lamella from lash line to lowest edge of
hair bearing part of brow

30. BELL’s PHENOMENON :
➢Protective Brainstem reflex where the eye normally move upwards
and outwards on closure of the eyelids
➢This reflex may be deficient in patients with ptosis

31. ➢Close the lids → try to elevate → check for corneal exposure
( OR )
➢Open eyes wide → ask the patient to close → Up and Out with no
Corneal Exposure

BELL’s PHENOMENON :

32. ➢GRADING :



GOOD > 2/3rd of Cornea goes up
FAIR ⅓ - 2/3rd of cornea goes up
POOR < ⅓ rd of cornea goes up
BELL’s PHENOMENON :

33. ➢Variants :
INVERSE BELL’s PHENOMENON UP & IN
REVERSE BELL’s PHENOMENON DOWN & OUT
PERVERSE BELL’s PHENOMENON Any direction
BELL’s PHENOMENON :

34. CORNEAL SENSATIONS :

➢A normal corneal sensation is essential for normal blink reflex and
prevention of exposure keratitis the following surgery.

➢ Quantity and quality of the tear film should be assessed.
➢Schirmer test, tear break up time (TBUT) and Tear meniscus
➢ Dry eye syndrome is a contraindication for ptosis surgery;
especially sling surgeries as it may cause corneal damage
postoperatively.

35. MARCUS GUNN JAW WINKING PHENOMENON :
➢Common synkinesis associated with congenital ptosis
➢Movement of the ptotic eyelid corresponding with the action of
mastication ( pterygoids, mylohyoid, digastric )
➢Ask the patient to perform a range of jaw maneuvers - sideward
movements of the jaw , opening and closure of the mouth and
protraction of the jaw
➢Any movement of the lid occuring with movement of the jaw points
toward underlying aberrant innervation

37. GRADING :

Grading based on eyelid position Grading based on mm
of eyelid excursion
MILD Maximum elevation of the ptotic lid to
the non ptotic position
2mm
MODERATEMaximum elevation up to the superior
limbus
3-4mm
SEVERE Maximum elevation beyond the
superior limbus with scleral show
>/= 5mm

38. PARAMETERS CONGENITAL ACQUIRED
MRD 1 Mild - Severe Mild - Severe
Upper Eyelid crease Weak or Absent in
normal position
Higher than normal
crease
LPS Function Reduced Near normal
Downgaze Eyelid Lag Eyelid drop
Palpebral Aperture Greater in downgazeLess in downgaze

39. INCREASED INNERVATION :
➢Elevate the ptotic lid → other lid has the tendency to droop
➢Based on Herring’s Law of Equal Innervation
➢After the surgery there is a chance of the other eye developing ptosis
and patient has to be warned that the contralateral eye may droop
following the correction of the greater ptotic lid

40. BLEPHAROPHIMOSIS :
➢Horizontal shortening of the palpebral fissures associated with
-Ptosis
-Telecanthus
-Epicanthal folds ( M/C : Epicanthus Inversus )
➢Ptosis present at birth with poor / absent levator function
➢May be associated with
-Malar hypoplasia
-Hypertelorism
-Fusion of the eyebrows
-Poorly developed nasal bridge

42. MYOGENIC PTOSIS :
ETIOLOGY :
a)Myotonic Dystrophy
b)Myasthenia Gravis
c)Chronic Progressive External Ophthalmoplegia
d)Oculopharyngeal Muscular Dystrophy
e)Fascioscapular Muscular Dystrophy
f)Congenital Myopathies
g)Mitochondriopathies ( MELAS , MERRF )
h)Orbital Rhabdomyosarcoma

43. MYOGENIC PTOSIS :

➢Bilateral , Symmetrical
➢Progressive
➢Severe ptosis
➢LPS Action : Moderate to Poor
➢Frontalis Overaction Brow elevation ,Chin lift , Head tilt
➢Generalized Ophthalmoplegia
➢Diplopia is uncommon
➢Poor Bell’s phenomenon
➢Orbicularis weakness

44. SIGNS AND SYMPTOMS :
➢MYOTONIC DYSTROPHY :
➔Arm weakness
➔Poor Bell’s Phenomenon
➔Cardiac conduction Abnormalities
➔Myotonia ( difficulty in relaxing the hand when gripping such as after
a handshake )
➔Polychromatic Christmas Tree cataracts / Pigmentary Retinopathy
➔Orbicularis muscle weakness → Lower lid retraction , difficulty in
closing and opening after forceful eye closure

45. SIGNS AND SYMPTOMS :

➢OCULOPHARYNGEAL MUSCULAR DYSTROPHY :
➔>50 years
➔Dysphagia
➔Dysphonia
➔Proximal muscle weakness
➔Complete ophthalmoplegia is not common
➔Normal retinal function
➔Intact Bell’s Phenomenon

46. SIGNS AND SYMPTOMS :

➢CHRONIC PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA :
➔Young to middle age
➔Males = Females
➔Ophthalmoparesis is seen after several months of ptosis
➔Pupils - Not affected
➔Constant progression
➔Exposure Keratopathy

47. SIGNS AND SYMPTOMS :

➢KEARNS SAYRE SYNDROME :
➔<20 years
➔Ataxia
➔Cardiac conduction defects
➔Abnormally high protein levels in the CSF
➔Pigmentary Retinopathy
➔Poor Bell’s Phenomenon
➔Optic Atrophy

48. MYOGENIC PTOSIS :
MRI , CT , USG ORBIT
→ Symmetrical thinning of EOM
ERG : Abnormal even in the absence of RPE Atrophy
VEP : Abnormal - increased latency in P100
MUSCLE BIOPSY : Definitive
→ Sarcolemmal Ragged Red fibres

49. APONEUROTIC PTOSIS :
➢Unilateral or Bilateral
➢Difficulty in reading ,climbing downstairs ( ptosis worsens in down gaze )
➢Eyelid crease displaced upwards
➢LPS action is Good : >/= 12mm
➢Visible Iris sign
➢DESMARRE’s SIGN
➢Positive Finger Test
➢Greater vertical lid length

50. APONEUROTIC PTOSIS :

CAUSES :
➔Ageing
➔Blepharochalasis
➔Children : VKC / Allergies → rubbing
➔Intraocular surgeries - glaucoma , cataract
➔DEHISCENCE : LPS - elongated & thinned out
➔DEGENERATION : Fatty infiltration of aponeurosis, muscle , mullers
➔DISINSERTION : Disinserts from tarsal insertion & folds over orbital
septum

53. NEUROMUSCULAR PTOSIS :
➢Defect at the level of nerve and muscle
➢Myasthenia Gravis
➢Autoimmune
➢Variable Ptosis
➢Females > males ( young ) ; Males > Females ( older )

54. NEUROMUSCULAR PTOSIS :

➢Usually affects the smaller muscles first
-( LPS → EOM → Orbicularis oculi )
➔Dysarthria
➔Dysphagia
➔Jaw fatigue
➔ Facial weakness

55. CHECK FOR MYASTHENIA GRAVIS :
➢FATIGABILITY :
-Ask the patient to look up continuously at least for 30 seconds →
check for drooping
-Change of >/= 2mm : positive
➢COGAN’s LID TWITCH :
-Look up → primary gaze → down to your fingers = twitch
➢EYE PEEK SIGN :
-Ask the patient to close the eye → as Orbicularis Oculi is also a
skeletal muscle there may be weakening of the muscle → eye
peeking

56. → FATIGABILITY TEST
EYE PEEK SIGN ←

57. EYELID RETRACTION :
➔In U/L ptosis : Hering’s Law
➔Cogan’s Lid Twitch
➔Spontaneous retraction - after staring straight ahead or looking up
for several minutes
➔Concomitant Thyroid Eye Disease

58. LAB STUDIES :
➔PHARMACOLOGIC TESTS :
➔Tensilon / Edrophonium Test I/V
-Elevation eyelids , improvement in diplopia and facial expression

➔Neostigmine I/M
-Improvement in ptosis and ocular motility

59. ➔Ice pack test : highest sensitivity
-Improvement of 2mm - positive

60. SEROLOGY :
➔AChR Antibodies
➔Anti - MUSK Antibodies - higher incidence of dysphagia , dysarthria ,
facial weakness and respiratory crisis
➔AChR antibodies are not specific and are associated with other
autoimmune conditions like SLE,RA

61. NEUROGENIC PTOSIS :
LOCATION :
1)Supranuclear - C/L ptosis
2)Nuclear
3)Fasicular
4)Peripheral Nerve - in the Subarachnoid space , cavernous sinus and
orbit

62. NEUROGENIC PTOSIS :

ETIOLOGY :
➢Congenital third nerve palsy
➢Acquired third nerve palsy
-Vascular - Ischaemic , Haemorrhagic , Aneurysmal
-Compressive / Tumor
-Inflammatory
-Demyelinating
-Infective
-Toxic
-Traumatic
➢ Horner’s Syndrome

63. MECHANICAL PTOSIS :
Due to excessive weight
➢Eyelid Mass
➢Giant Papillae / VKC
➢Multiple Chalazion
➢Orbital Mass
➢Scarring

64. MYOGENIC PTOSIS :
OCULAR MYASTHENIA :
Medical Management Indications :
➔Ptosis covering visual axis
➔Diplopia
➔Appearance

65. ➢ChE - Inhibitors : Pyridostigmine 90-300 mg/day
➔Wait for 3-6 weeks for t8he response
➔Ptosis responds better than Diplopia
➔60-80 % initial satisfactory response
-60-80% sustained response
-20-40 % wear out - early/late
➢Steroids : Intravenous MethylPrednisolone in Acute cases of Ptosis =
Loading Dose of 500 mg → Oral Steroids
➔Diplopia responds better

66. ➔Steroids - Escalating dose Schedule ( from high to low dose tapering )
(or) - Pyramidal dose Schedule ( starting with low doses and
gradually increase the dose till maximum effect is seen and then
tapered ) = more safer
➔ OTHERS :
-Azathioprine
-Mmf , Tacrolimus , Cyclosporine
-Thymectomy
-Supportive measures → Taping / Crutch Glasses
-Surgery

67. SURGERIES :
Depends on
➔Amount of Ptosis
➔Levator Action
➔Associated Co Morbidities

➢Frontalis muscle suspension is the gold standard for the treatment
of congenital ptosis

68. SURGERY :
SAFETY ENHANCED SURGERY :
➢Undercorrect - just enough to expose the pupil
➢Avoid levator surgery as it is irreversible
➢Reversible surgery : Silicone sling
➢Shift the palpebral fissure by elevating the lower eyelid - by central
lower lid retraction leaving medial & lateral parts
➢Temporary suture tarsorrhaphy

69. NEUROGENIC PTOSIS :
➢Reversible or Irreversible
➢Initial management : is always conservative
➢Diplopia : patching / prisms / botox
➢Observe the natural course of disease for 3-6 months
➢Optimal Squint correction first

70. APONEUROTIC PTOSIS :
SURGERIES :
➢Levator Reattachment
➢Levator Plication
➢Levator Resection ( levator degeneration )
➢Mullerectomy
➢Fasanella Servat

71. LEVATOR REATTACHMENT :
➢Acquired Aponeurotic Ptosis
➢Levator Disinsertion
➢> 8mm LPSA
➢Reinsert to the middle of the tarsus LPSA : 8-9mm
➢Hang back to upper edge of the tarsus if LPSA : 10-11mm
➢Hang back to 2mm from upper edge of tarsus if LPSA : >/= 12mm

72. LEVATOR RESECTION :
INDICATIONS :
➢Severe ptosis
➢Levator action <8mm
➢Fat infiltration
APPROACHES :
→ Skin approach ( Everbusch’s )
→ Conjunctival Approach ( Blaskowich’s)

73. → The levator is dissected off the conjunctiva below and the
preaponeurotic fat above it
→ The redundant portion of the aponeurosis is excised and lid
crease is formed with three interrupted 6-O vicryl sutures
→ A Bandage contact lens / Frost suture are placed to minimize
corneal exposure during early postop period

76. COMPLICATIONS :
➢Corneal Exposure
➢Eyelid level too high or too low
➢Conjunctival Prolapse
➢Contour Abnormality
➢Lash ptosis
➢Entropion
➢Lash eversion
➢Ectropion

77. LEVATOR PLICATION :
➢Levator Dehiscence NOT Disinsertion
➢Usually while surgery after the sub orbicularis separation – a layer of
tissue is seen on the top of conjunctiva
➢> 12mm LPSA
➢6mm Plication → for 1 mm ptosis
➢Maximum 18mm ( 3mm ptosis )

78. FASANELLA SERVAT PROCEDURE :
➢Adequate tarsal height
➢At least 8mm vertical tarsal height
➢Aim for at least 4mm residual tarsal height
➢For 1mm of correction = 2mm excision of tarsus is done

79. FASANELLA SERVAT PROCEDURE :

PRINCIPLE :
➢The upper border of tarsus is excised with lower part of Muller’s
muscle and the overlying conjunctiva
INDICATIONS :
➔Mild congenital ptosis with LPSA >10mm
➔Horner’s syndrome
➔Minimal Residual Ptosis
➔Myogenic Ptosis
➔Neurogenic Ptosis

80. FASANELLA SERVAT PROCEDURE :

PROCEDURE :
➢4 - O silk traction sutures at the superior border of tarsus
➢Eversion of the lid , marking the amount of tarsus to be excised
➢Excision of the tarsoconjunctival lamina with underlying Muller’s
muscle
➢Suturing the excised edges with a plain 6-O catgut suture
➢It also involves the excision of normal tarsus hence leading to upper
lid instability

82. COMPLICATIONS :
➢Corneal Abrasion
➢Foreign Body Sensation
➢Central Peaking
➢Retraction of tarsus
➢Skin crease Lowering ( if the height of the tarsal plate is reduced
below the preoperative skin crease level )

83. ➢The action of Frontalis muscle - lifting of eyelid is enhanced by
connecting the frontalis muscle and eyebrow to the eyelid with a
subcutaneous sling for which various materials are used
➢Bilateral suspension with weakening or division of the other levator
muscle if this normal
FRONTALIS SLING :

84. INDICATIONS :
➢Ptosis <4mm of LPS function
➢The prevention of of amblyopia in an infant with severe ptosis
TYPES
➢Crowford Frontalis Sling : Autologous Fascia Lata
-Procedure of choice for a sling procedure if there is no
contraindication to harvesting fascia
➢Fox Pentagon : Nonautologous material
-Procedure of choice with Foreign Material

85. SUSPENSORY MATERIALS :
➢Autogenous - Fascia lata , Temporalis Fascia
➢Non Autogenpus -
-Integrable : eg - Mersilene mesh, Gortex
-Non Integrable : Supramid / Prolene suture , Silicone rod
-> Preferred in very young children who are too small for fascia lata to
be harvested

86. CRAWFORD BROW SUSPENSION/FRONTALIS SLING :
➢Make a medial , central , lateral horizontal skin mark on the eyelid
2-3mm from the lash line
➢Make three marks above the eyebrow
➢Make stab incisions along these marks , widening the forehead
incisions
➢Use a fascial needle to pass each strip of fascia
➢The fascia should be deep to the orbicularis muscle and superficial
to the tarsal plate and orbital septum

87. ➢Commonly done under General Anaesthesia
➢Skin crease incision is made
➢Skin and orbicularis are separated
➢Three small skin incisions are put on the forehead just above the
brow , the central one a little above the rest and deeper tissues are
exposed
➢The two blades of artery forceps are passed between the two
incisions
➢The lower ends of the material are fixed to the front of the tarsal
plate

88. ➢Pull up the two triangles of fascia to give a symmetrical lid curvepull
one strip from each eyebrow incision through the forehead incision.
Tie the strips together
➢Close the foreehead and eyebrow incisions

90. FOX PENTAGON :
➢Make two skin marks between those that would me made for Crawford
technique and three higher incisions as crawford technique
➢Make stab incisions through these marks
➢Push an appropriate needle through incisions and pull the material
deep to the orbicularis muscle
➢Pull up the sling and bury it deeply below the forehead incision

91. COMPLICATIONS :
➢Corneal exposure ( if the eyelid is too higher )
➢Sling material can be cut
➢Granulomas

93. REFERENCES :
➢Kanski’s Clinical Ophthalmology
➢Zia Chaudhuri PostGraduate Ophthalmology
➢Collin’s Manual of Systematic Eyelid Surgery
➢Dutta Modern Ophthalmology
➢Eye Wiki Ophthalmology
➢Ifocus youtube

94. THANK YOU !!