CLASSIFICATION OF PTOSIS
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CLASSIFICATION OF PTOSIS. 1. Neurogenic. Third nerve palsy. Third nerve misdirection. Horner syndrome. Marcus Gunn jaw-winking syndrome. 2. Myogenic. Myasthenia gravis. Myotonic dystrophy. Ocular myopathies. Simple congenital. Blepharophimosis syndrome. 3. Aponeurotic.

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CLASSIFICATION OF PTOSIS

1. Neurogenic

  • Third nerve palsy

  • Third nerve misdirection

  • Horner syndrome

  • Marcus Gunn jaw-winking syndrome

2. Myogenic

  • Myasthenia gravis

  • Myotonic dystrophy

  • Ocular myopathies

  • Simple congenital

  • Blepharophimosis syndrome

3. Aponeurotic

4. Mechanical


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PTOSIS

1. Evaluation

  • Pseudoptosis

  • True ptosis

2. Classification

  • Neurogenic ptosis

  • Myogenic ptosis

  • Aponeurotic ptosis

  • Mechanical ptosis

3. Treatment options


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Causes of pseudoptosis

Contralateral lid retraction

Lack of lid support

Ipsilateral hypotropia

Brow ptosis-excessive

eyebrow skin

Dermatochalasis- excessive

eyelid skin


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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)


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Upper lid excursion

  • Reflects levator function

  • Normal (15 mm or more)

  • Good (12 mm or more)

  • Fair (5-11 mm)

  • Poor (4 mm or less)


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Vertical fissure height

  • 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


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Upper lid crease

Pretarsal show

fold

crease

  • Distance between lash line and skin fold

  • in primary position of gaze

  • 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


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Bell’s phenomenon

Upward rotation of globe on lid closure

Good

Poor - risk of postoperative

corneal exposure


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Left third nerve palsy

Severe unilateral ptosis and

Normal abduction

defective adduction

Defective elevation

Defective depression


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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 primary

position

Worse on right gaze

Normal on left gaze


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Horner syndrome

  • Caused by oculosympathetic

  • palsy

  • Usually unilateral mild

  • ptosis and miosis

  • Normal pupillary reactions

  • Slight elevation of lower lid

  • Iris hypochromia if

  • congenital or longstanding

  • Anhydrosis if lesion is below

  • superior cervical ganglion


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Important causes of Horner syndrome

Central

(first order neurone)

Posterior hypothalamus

  • Brainstem disease

  • (vascular, demyelination)

  • Spinal cord disease

  • (syringomyelia, tumours)

Pre-ganglionic

(second order neurone)

Superior cervical

ganglion

  • Intrathoracic lesions

  • (Pancoast tumour, aneurysm)

  • Neck lesions

  • (glands, trauma)

Post-ganglionic

(third order neurone)

  • Internal carotid artery disease

Ciliospinal centre of

Budge( C8 - T2 )

  • Cavernous sinus mass


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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

Contralateral movement of jaw

Opening of mouth


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Myasthenia Gravis

1. Clinical features

  • Uncommon, typically affects young women

  • Weakness and fatiguability of voluntary musculature

  • Three types - ocular, bulbar and generalized

2. Investigations

  • Edrophonium (Camiston) test

  • Electromyography to confirm fatigue

  • Antibodies to acetylcholine receptors

  • CT or MRI for presence of thymoma

3. Treatment options

  • Medical - anticholinesterases, steroids and azathioprine

  • Thymectomy


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Ocular myasthenia

Ptosis

Diplopia

  • Insidious, bilateral but asymmetrical

  • Intermittent and usually vertical

  • Worse with fatigue and in upgaze

  • Ptotic lid may show ‘twitch’ and

  • ‘hop’ signs


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Edrophonium test

Before injection

Positive result

  • Measure amount of ptosis or

  • diplopia before injection

  • Inject i.v. test dose of edrophonium

  • (0.2 ml-2 mg)

  • Inject remaining (0.8 ml-8 mg) if no

  • hypersensitivity

  • Inject i.v. atropine 0.3 mg


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Myotonic dystrophy

Facial weakness and

ptosis

Release of grip difficult

  • Muscle wasting

  • Hypogonadism

  • Frontal baldness in males

  • Involvement of tongue and pharyngeal muscles

  • Intellectual deterioration

  • Ophthalmoplegia - uncommon

  • Presenile stellate cataracts


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Ocular myopathies

Ocular features

Clinical types

  • Isolated

  • Ptosis - slowly progressive and

  • symmetrical

  • Oculopharyngeal dystrophy

  • Ophthalmoplegia - slowly

  • progressive and symmetrical

  • (no diplopia)

  • Kearns-Sayre syndrome

  • (pigmentary retinopathy)


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Simple congenital ptosis

  • Developmental dystrophy of levator muscle

  • Occasionally associated with weakness of superior rectus

In downgaze ptotic eyelid is slightly

higher

Unilateral or bilateral ptosis of varying

severity

Frequent absence of upper lid crease

Usually poor levator function


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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


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Aponeurotic ptosis

  • Weakness of levator aponeurosis

  • Causes - involutional, postoperative and blepharochalasis

Mild

High upper lid crease

Good levator function

Severe

Absent upper lid crease

Deep sulcus


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Mechanical ptosis

Causes

Dermatochalasis

Large tumours

Severe lid oedema

Anterior orbital lesions


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Fasanella-Servat procedure

Indicated for mild ptosis with good levator function

..

Excision of upper border of tarsus, lower border of Muller muscle

and overlying conjunctiva


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Levator resection

Indicated for any ptosis provided levator function is at least 5 mm

Shortening of levator complex

Amount determined by levator

function and severity of ptosis


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Frontalis brow suspension

Main indications

  • Severe ptosis with poor levator function ( 4 mm or less )

  • Marcus Gunn jaw-winking syndrome

Attachment of tarsus to frontalis muscle with sling