Simple Congenital Ptosis.pptx

This is my case report which I've came across during my posting at Oculoplast posting, patient was a young female of 8 years old her parents brought her with chief complain of dropping of upperlid of RE the problem was from birth......

1. CLINICAL CASE PRESENTATION LUMBINI EYE INSTITUTE AND RESEARCH CENTRE (LEIRC), NEPAL. SUBMITTED BY: PRATIBHA GIRI B.OPTOMETRY BOPT-234 1

2. OUTLINES CASE DETAILS PRELIMINARY EXAMINATION OCULAR REFRACTION SLIT LAMP EXAMINATION ORTHOPTIC EVALUATION PTOSIS EVALUATION TREATMENT PLAN BRIEF DETAILS BOPT-234 2

3. CASE DETAILS DEMOGRAPHIC DETAIL Name = XXXX Age/Sex = 8/F Occupation = Student Date of visit = 15 June 2022 BOPT-234 3

4. CHIEF COMPLAINTS Drooping of upper lid RE since childhood acc . to parents PRESENT ILLNESS Drooping of upper lid of RE since birth NO H/O ANY TRAUMA NO H/O OF ANY PAST MEDICATION NO H/O ANY SYSTEMIC ILLNESS NO SUCH H/O OF OCULAR SURGERY NO H/O ANY OCULAR ALLERGY NO H/O CURRENT TREATMENT BOPT-234 4

5. BIRTH HISTORY PENATAL HISTORY NATAL HISTRY POSTNATAL HISTORY Mother health was good during the pregnancy days. Patient was delivered at home. Born with good health with APGAR Score 2. She have a one boy earlier with normal delivery. Born with normal gestation time. No H/O of resuscitation at birth. No H/O of maternal illness. Child was 2.5 kg . No medical H/O of convulsion , jaundice and fever. FAMILY HISTORY PEDIGREE TREE BOPT-234 5

6. PRELIMINARY EXAMINATION PARAMETERS OD OS VA [UNAIDED] 6/9 6/6 [P] VA [PH] 6/6[P] upper lid lifted 6/6 HEAD POSTURE NORMAL NORMAL FACIAL SYMMETRY NORMAL NORMAL PUPIL FUNCTION TEST [Direct and consensual] PERRRLA [NO RAPD] PERRRLA [ NO RAPD] BOPT-234 6

7. SLITLAMP EXAMINATION PARAMETERS OD OS EYELASHES NORMAL NORMAL EYELIDS UL DROOPING FLAT CONJUNCTIVA CLEAR CLEAR CORNEA CLEAR CLEAR AC QUIET [VH IV] QUIET [VH IV] IRIS NORMAL BROWN NORMAL BROWN PUPIL PERRRLA [NO RAPD] PERRRLA [NO RAPD] LENS CLEAR CLEAR BOPT-234 7

8. OCULAR REFRACTION PARAMETERS OD OS VA [PH] 6/6[P] lid lifted 6/6 OBJECTIVE REFRACTION +1.00 DSPH +0.50 DSPH/-O.50 DCYL*180 SUBJECTIVE REFRACTION +O.5O DSPH -0.25 DCYL*180 BCVA 6/6 6/6 BOPT-234 8

9. ORTHOPTIC EVALUATION PARAMETERS OD OS BCVA 6/6 6/6 HIRSCHBEG TEST CSM/ SYMMETRY CSM/ SYMMETRY NPC TO THE NOSE TO THE NOSE COVER TEST [SC] ORTHO ORTHO EOM TEST FULL AND FREE IN ALL 9 GAZE FULL AND FREE IN ALL 9 GAZE PUPILLARY EXAM.. [direct and consensual] PERRRLA [NO RAPD] PERRRLA [NO RAPD]. NPA 10cm 10cm AA 10D 10D BOPT-234 9

10. FUNDUS EXAMINATION OD MEDIA = Clear C/D = 0.2 COLOR = Pink MARGINS =Distinct ,flat A/V = 2/3 +SVP MACULA = Clear +FR OS MEDIA = Clear C/D = 0.2 COLOR = Pink MARGINS = Distinct ,flat A/V = 2/3 +SVP MACULA = Clear +FR BOPT-234 10

11. PTOSIS HISTORY TAKING NO H/O OF TRAUMA NO H/O PROGRESSION NO H/O SHALLOWING DIFFICULTY NO H/O MUSCLE WEAKNESS NO H/O OF SURGERY NO FAMILY H/O PTOSIS NO H/O SLEEPY/TIREDNESS NO H/O PAIN NO H/O DIPLOPIA ON EXAMINATION= NO E/O OF HEAD TILT E/O OF CHIN UP NO E/O FACIAL SYMMETRY BOPT-234 11

12. PTOSIS EVALUATION BOPT-234 12 SN PARAMETERS OD OS 1. BCVA 6/6 6/6 2. FRONTAL OVERACTION ABSENT ABSENT 3. EYEBROW SYMMETRY SYMMETRY 4. EOM FULL AND FREE FULL AND FREE 5. IPFH 6mm 10mm 6. HPFW 26mm 26mm 7. MRD1 -2mm +3mm 8. ULC ABSENT PRESENT 9. ULC HT 0mm 6mm 10. LPSF 3mm 12mm 11. MGJW ABSENT ABSENT

13. SN PARAMETERS OD OS 12. LAGOPTHALMOS ABSENT ABSENT 13. SCLERA SHOW +2mm ABSENT 14. SCHIRMER’S 15mm 20mm 15. K-SENSITIVITY INTACT INTACT 16. NCT 17 mm of hg 12 mm of hg 17. BELL’S POOR GOOD 18. K-READING H=42.37*180 V=42.75*90 -- 19. PHENYL NEPHRIN TEST NEGATIVE -- 20. ICE PACK TEST NEGATIVE -- BOPT-234 13

14. FINAL DIAGNOSIS BOPT-234 14

15. DIFFERENTIAL DIAGNOSIS TRAUMATIC PTOSIS CONGENITAL FIBROSIS OF EOM THIRD NERVE PALSY BLEPHAROPHIMOSIS SYNDROME SIMPLE CONGENITAL PTOSIS BOPT-234 15

16. FINAL DIAGNOSIS RE SIMPLE CONGENITAL PTOSIS DEGREE OF PTOSIS= SEVERE PTOSIS OF 4mm PLAN RE FRONTALIS SLING UNDER GA BOPT-234 16

17. PTOSIS INTODUCTION Ptosis is an abnormally low position of the upper lid in which the upper lid covers more than 3mm of the cornea. CLASSIFICATION OF PTOSIS Congenital ptosis [75%] Acquired ptosis [25%] Unilateral or bilateral Complete or partial Symmetrical or asymmetrical BOPT-234 17

18. PTOSIS BOPT-234 18

19. ANATOMY Levator palpebrae superiosis Mullers muscle BOPT-234 19

20. CONGENITAL PTOSIS Simple congenital ptosis. Congenital ptosis with associated weakness of superior rectus muscle. Blepharophimosis syndrome. Congenital synkinetic ptosis. ACQUIRED PTOSIS Neurogenic ptosis. 3d neve palsy Horner’s syndrome Multiple sclerosis Opthalmoplegic migraine. Acquired myogenic ptosis Myasthenia gravis Myotonic dystrophy Aponeurotic ptosis Involutional ptosis Post surgical Mechanical ptosis Tumour /swelling BOPT-234 20

21. PSEUDOPTOSIS Brow ptosis I psilateral hypotropia BOPT-234 21

22. Prosthetic eye Enopthalmos BOPT-234 22

23. CLINICAL MANIFESTATION SYMPTOMS Visual disturbance if pupil is involved Asymptomatic if pupil is uncovered Cosmetic disfiguration Diplopia Abnormal head posture and head tilt Raised eyebrows SIGNS Drooping of lid ith variable severity. Lid crease is diminished o absent. Lid lag on don gaze. LPS fuction may be of variable severity. BOPT-234 23

24. EXAMINATION Head posture Facial symmetry Periocular fullness Frontalis overaction Lid skin laxity Telecanthus /epicanthus inversus BOPT-234 24

25. PTOSIS EVALUATION BCVA To assess the amblyopia in congenital ptosis. REFRACTION Cycloplegic refraction is indicated in all children to avoid astigmatism on the ptotic side . OCULAR MOTILITY To R/O the 3 rd nerve palsy in neurogenic ptosis. Vertical strabismus if present need to be corrected prior to ptosis correction. BOPT-234 25

26. Measurement of amount of ptosis BOPT-234 26

27. VERTICAL PALPEBRAL FISSURE HEIGHT BOPT-234 27

28. MARGINAL REFLEX DISTANCE BOPT-234 28

29. BERKES METHOD FOR LFA BOPT-234 29

30. LID CREASE POSITION BOPT-234 30

31. PHENYL NEPHRINE TEST MGJW BOPT-234 31

32. ICE PACK TEST SCHIMER TEST BOPT-234 32

33. TENSILONS TEST BELL’S PHENOMENA BOPT-234 33

34. TREATMENT NON-SURGICAL LID CRUTCHES HAPTIC CONTACT LENS BOPT-234 34

35. SELECTION OF CORRECT SURGERY INTERVENTION I ndications Complete ptosis Abnormal head posture Amblyopia Laterality Psychological impact C ontraindications Poor orbicularis muscle function Loss of blink reflex Corneal sensitivity Keratitis sicca BOPT-234 35

36. MULLERECTOMY Mild ptosis Phenylnephrine test positive BOPT-234 36

37. MANAGEMENT OF , MODERATE PTOSIS [LA 4mm] Levator resection BOPT-234 37

38. COMPLICATIONS OF LEVATOR RESECTION Lid lag Lagopthalmos Undercorrection is common Overcorrection is rare Lid notch Exposure keratopathy Superior fornix prolapse BOPT-234 38

39. SEVERE PTOSIS[LA 4mm] Poor levator action FRONTALIS SLING BOPT-234 39

40. Materials for sling Autogenous Synthetic BOPT-234 40

41. COMPLICATIONS OF SLING Lid lag Lagopthalmos Undercorrection Overcorrection Recurrence Lid notching/poor contour Entropion/ectropion Infection/granuloma formation BOPT-234 41

42. COMPLICATIONS ASYMMETRY MADAROSIS BOPT-234 42

43. WOUND DEHISCENCE UNFAVORABLE SCAR BOPT-234 43

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