PTOSIS.pptx

you will get knowledge about the ptosis, its different types, its examination, its measurement, its treatment in detail.
different eyelid muscles such as LPS, Orbicularis oculi and frontalis are also explained.

1. Ptosis Ptosis is an abnormally low position of the upper lid. Grading and severity Normally upper eyelid cover 1/6 th of cornea Mild < or = 2mm Moderate = 3mm Severe > 4mm

2. FUNCTIONAL ANATOMY Levator Palpebral Superioris (LPS): Is the primary muscle responsible for lid elevation. It arises from the back of the orbit and extends forwards over the cone of eye muscles. It inserts into the eyelid and the tarsal plate, a fibrous semicircular structure which gives the upper eyelid its shape. The LPS is supplied by the superior division of the oculomotor nerve.

3. Muller’s Muscle: The way that the LPS attaches to the tarsal plate is modified by the underlying Müller's muscle. This involuntary muscle, comprising sympathetically innervated smooth muscle Has the capacity to 'tighten' the attachment and so raise the lid a few millimetres . Frontalis and Orbicularis Oculi muscles: Both muscles supplied by the facial nerve. Frontalis contraction helps to elevate the lid by acting indirectly on the surrounding soft tissues, while orbicularis oculi contraction depresses the eyelid.

4. CLASSIFICATION It may be Acquired Congenital Acquired Neurogenic Myogenic Aponeurotic Mechanical Neurotoxic

5. 1). Neurogenic It caused by an innervational defect such as 3 rd nerve paresis and Horner's Syndrome. 3 rd nerve misdirection syndrome Rare, unilateral Aberrant regeneration following acquired 3 rd nerve palsy Bizarre movements of upper lid accompany eye movements Pupil is occasionally involved Right ptosis primary position Worse on right gaze Normal on left gaze

6. Horner syndrome: It is a relatively rare disorder characterized by: A constricted pupil (miosis) Drooping of the upper eyelid (ptosis) Absence of sweating of the face (anhidrosis) Sinking of the eyeball into the bony cavity that protects the eye (enophthalmos)

7. 2). MAYOGENIC : Caused by the myopathy of the levator muscle itself or by the impairment of the transmission of impulses at the neuro muscular junction Acquired myogenic occurs in myasthenia gravis myotonic dystrophy and progressive external ophthalmoplegia.

8. 3). APONEURATIC Caused by a defect in the levator aponeurosis Involutional ptosis Aponeuratic ptosis also called senile or involutional ptosis, is the most common type of acquired ptosis. It is caused by a disinsertion or dehiscence of the levator aponeurosis from the tarsus. Clinical exam reveals a high lid crease, generally good levator function and typically worsening of the ptosis on downgaze. Such patients tend to do well with surgical correction which involves advancement and reattachment of the levator aponeurosis to the anterior tarsal surface.

9. 4). MECHANICAL : With mechanical ptosis, the eyelid is weighed down by excessive skin or a mass. Traumatic ptosis is caused by an injury to the eyelid. E ither due to an accident or other eye trauma. This injury compromises or weakens the levator muscle

10. CONGENITAL Simple congenital ptosis Congenital ptosis Congenital synkinetic ptosis Blepharophimosis Syndrome 1). Simple congenital ptosis Not associated with any anomaly

11. 2). Congenital ptosis It results from a failure of neuronal migration or development with muscular sequalae. Superior Rectus weakness Compensatory Chin elevation Absent upper lid crease In downward gaze the ptotic lid is higher then the normal because of poor relaxation of the levator function 3). Congenital Synkinetic ptosis Marcus Gun Jaw winking Ptosis

12. MARCUS GUN JAW WINKING PTOSIS About 5% of the congenital cases are associated with the Marcus gun jaw winking phenomenon. Retraction of the ptotic lid in conjunction with stimulation of the ipsilateral Pterygoid muscle by chewing, sucking, opening the mouth Less common stimuli to winking include jaw protrusion, smiling, swallowing and clenching of teeth Jaw winking does not improve with age Exact aetiology is unclear

13. PSEUDOPTOSIS False impression of the ptosis which may be caused by: LACK OF SUPPORT Lack of support of the lids by the globe ma be due to the orbital volume deficient associated with enophthalmos. CONTRALATERAL LID RETRACTION Which is detected by comparing the levels of upper eyelids the margin of the upper lid mat cover the superior 2mm of cornea IPSILATERAL HYPOTROPIA Upper lid follows the globe downward BROW PTOSIS Due to excessive skin on the brow

14. SIGN and SYMPTOMS OF PTOSIS Dropping eyelid Raising of the eyebrows to lift the eyelids for better vision Watery eye Tilting the head Aching in and around the eyes Looking tired Double vision Difficulty closing the eyes or blinking

15. EVALUATION OF PTOSIS: History: Age of onset Duration One/both eye Diurnal variability Associated history: Diplopia Dysphagia Muscle weakness Vision

16. Associated with: Jaw movements Abnormal ocular movements Abnormal head posture History of: Trauma or previous surgery Poisoning Use of steroid drops Any reaction with anesthesia Bleeding tendency Previous photographs may prove to be of great help . Is there a family history of ptosis or of other muscle weakness?

17. OCULAR EXAMINATION Normal position of eyelids: The normal upper eyelid in primary position Crosses the iris b/w the limbus (junction of the iris and sclera) and the pupil Usually 1 mm to 2 mm below the limbus The lower lid touches or crosses slightly above the limbus . Normally there is no sclera showing above the iris. Palpebral fissures: It is normally 9 mm to 12 mm from upper to lower lid margin Visual Acuity: Best-corrected visual acuity should be assessed to record any amblyopia if present, especially in cases of congenital ptosis.

18. PUPILLARY EXAMINATION TO diagnosis Horner’s syndrome Involvement in a case of third nerve palsy TOTAL UNILATERAL PTOSIS Complete third nerve palsy. MILD TO MODERATE PTOSIS Horner's syndrome partial third nerve palsy. MILD TO MODERATE BILATERAL PTOSIS Neuromuscular disorders such as MG Muscular dystrophy Ocular myopathy

19. Measurements Margin reflex distance Vertical fissure height LPS action Lid crease level Lid level on down gaze

20. 1). MARGIN REFLEX DISTANCE: Margin-to-reflex distance 1 (MRD1) When light is thrown on the cornea, a reflection occurs. The distance from the central pupillary light reflex to the upper eyelid margin with the eye in primary gaze. If the margin is above the light reflex the MRD 1 is a + ve value. If the lid margin is below the corneal reflex in cases of very severe ptosis the MRD 1 would be a – ve value.

21. 2). Vertical fissure height The distance between the upper and lower eyelid in vertical alignment with the center of the pupil in primary gaze, with the patient’s brow relaxed. Normal – 9-10mm in primary gaze Should be seen in up gaze, down gaze and primary gaze Amount of ptosis = difference in palpebral apertures in unilateral ptosis or Difference from normal in bilateral ptosis

22. 3). Levator function assessment It is determined by the lid excursion caused by LPS muscle (Burke’s method). Patient is asked to look down and thumb of one hand is placed firmly against the eyebrow of the patient (to block the action of frontalis muscle) by the examiner. Then the patient is asked to look up and the amount of upper lid excursion is measured with a ruler held in the other hand by the examiner. Levator function is graded as follows: Normal 15 mm Good 8 mm or more Fair 5-7 mm Poor 4 mm or less

23. Investigation Serum acetylcholine receptor assay Tensilon test EMG ECG ERG T3, T4, TSH

24. TREATMENT CONGENITAL PTOSIS Almost always surgical treatment AQUIRED PTOSIS Treat the underlying cause Surgey Fasanella servant operation Levator resection Frontalis sling operation

25. Fasanella-Servat procedure Indicated for mild ptosis(1.5-2mm) with good levator function

26. Levator resection Indicated for any ptosis provided levator function is at least 5mm. Contraindicated in patients having severe ptosis with poor levator function.

27. Frontalis brow suspension Used in severe ptosis with poor levator function (4 mm or less). The tarsal plate is suspended from the frontalis muscle with a sling consisting of autologous fascia lata or non absorbable material such as prolene or silicon. Marcus Gunn jaw-winking syndrome