ptosis
TRANSCRIPT
CLASSIFICATION OF PTOSIS
• Third nerve palsy1. Neurogenic
• Third nerve misdirection• Horner syndrome• Marcus Gunn jaw-winking syndrome
• Myasthenia gravis• Myotonic dystrophy• Ocular myopathies• Simple congenital
2. Myogenic
3. Aponeurotic4. Mechanical
• Blepharophimosis syndrome
PTOSIS
• Pseudoptosis• True ptosis
1. Evaluation
• Neurogenic ptosis• Myogenic ptosis• Aponeurotic ptosis• Mechanical ptosis
2. Classification
3. Treatment options
Causes of pseudoptosis
Ipsilateral hypotropia Brow ptosis - excessive eyebrow skin
Dermatochalasis - excessiveeyelid skin
Lack of lid support Contralateral lid retraction
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)
• Reflects levator function
• Normal (15 mm or more)
• Good (12 mm or more)
• Fair (5-11 mm)
Upper lid excursion
• Poor (4 mm or less)
• Distance between upper and lower lid margins
• Normal upper lid margin rests about 2 mm below upper limbus
• Normal lower lid margin rests 1 mm above lower limbus
• Amount of unilateral ptosis is determined by comparison
Vertical fissure height
Upper lid crease
• Distance between lid margin and lid crease in down-gaze
• Normals - females 10 mm; males 8 mm• Absence in congenital ptosis indicates poor levator function
• High crease suggests an aponeurotic defect
• Distance between lash line and skin fold in primary position of gaze
Pretarsal show
crease fold
Bell’s phenomenonUpward rotation of globe on lid closure
Good Poor - risk of postoperativecorneal exposure
Left third nerve palsy
Severe unilateral ptosis anddefective adduction Normal abduction
Defective elevation Defective depression
Right third nerve misdirection• Rare, unilateral• Aberrant regeneration following acquired third nerve palsy• Pupil is occasionally involved• Bizarre movements of upper lid accompany eye movements
Right ptosis in primaryposition
Worse on right gaze Normal on left gaze
Horner syndrome
• Caused by oculosympathetic palsy
• Usually unilateral mild ptosis and miosis
• Slight elevation of lower lid
• Normal pupillary reactions
• Iris hypochromia if congenital or longstanding
• Anhydrosis if lesion is below superior cervical ganglion
Important causes of Horner syndromeCentral
(first order neurone)• Brainstem disease (vascular, demyelination)
• Spinal cord disease (syringomyelia, tumours)
Pre-ganglionic (second order neurone)
• Intrathoracic lesions (Pancoast tumour, aneurysm)
• Neck lesions (glands, trauma)
Post-ganglionic (third order neurone)
• Internal carotid artery disease• Cavernous sinus mass
Posterior hypothalamus
Ciliospinal centre of Budge( C8 - T2 )
Superior cervicalganglion
Marcus Gunn jaw-winking syndrome• Accounts for about 5% of all cases of congenital ptosis• Retraction or ‘wink’ of ptotic lid in conjunction with stimulation of ipsilateral pterygoid muscles
Opening of mouth Contralateral movement of jaw
Myasthenia Gravis
• Uncommon, typically affects young women1. Clinical features
• Edrophonium (Camiston) test2. Investigations
• Medical - anticholinesterases, steroids and azathioprine3. Treatment options
• Weakness and fatiguability of voluntary musculature• Three types - ocular, bulbar and generalized
• Antibodies to acetylcholine receptors• CT or MRI for presence of thymoma
• Electromyography to confirm fatigue
• Thymectomy
Ocular myasthenia
• Insidious, bilateral but asymmetrical• Worse with fatigue and in upgaze
Ptosis
• Ptotic lid may show ‘twitch’ and ‘hop’ signs
• Intermittent and usually vertical
Diplopia
Edrophonium test
• Measure amount of ptosis or diplopia before injection
• Inject i.v. atropine 0.3 mg
• Inject i.v. test dose of edrophonium (0.2 ml-2 mg)• Inject remaining (0.8 ml-8 mg) if no hypersensitivity
Before injection Positive result
Myotonic dystrophyFacial weakness and ptosis
• Involvement of tongue and pharyngeal muscles
• Ophthalmoplegia - uncommon
• Muscle wasting • Hypogonadism• Frontal baldness in males• Intellectual deterioration• Presenile stellate cataracts
Release of grip difficult
Ocular myopathies
• Isolated
• Oculopharyngeal dystrophy
• Kearns-Sayre syndrome (pigmentary retinopathy)
• Ptosis - slowly progressive and symmetrical• Ophthalmoplegia - slowly progressive and symmetrical (no diplopia)
Clinical types Ocular features
Simple congenital ptosis• Developmental dystrophy of levator muscle• Occasionally associated with weakness of superior rectus
Unilateral or bilateral ptosis of varying severity
In downgaze ptotic eyelid is slightly higher
Frequent absence of upper lid crease Usually poor levator function
Blepharophimosis syndrome
• Rare congenital disorder
• Dominant inheritance
• Moderate to severe symmetrical ptosis• Short horizontal palpebral aperture• Telecanthus (lateral displacement of medial canthus)• Epicanthus inversus (lower lid fold larger than upper)• Lateral inferior ectropion• Poorly developed nasal bridge and hypoplasia of superior orbital rims
Aponeurotic ptosis• Weakness of levator aponeurosis• Causes - involutional, postoperative and blepharochalasis
High upper lid crease Good levator function
Absent upper lid crease Deep sulcus
Mild
Severe
Fasanella-Servat procedure
Excision of upper border of tarsus, lower border of Muller muscle and overlying conjunctiva
Indicated for mild ptosis with good levator function
..
Levator resection
Shortening of levator complex
Indicated for any ptosis provided levator function is at least 5 mm
Amount determined by levator function and severity of ptosis