ptosis - dr.divya

blepharoptosis

Dr.Dhivya pratheepa

Blepharoptosis • Greek word : to fall• Is abnormal infero displacement of

upper eye lid

classificaton

classification

Neurogenic

• Third nerve palsy • Horner’s syndrome

Myogenic

• Myasthenia gravis• Myotonic dystrophy• OPMD• CPEO

classification

Aponeurotic

• Involutional • Post operative

Mechanical

• Tumor • Dermatochalasis • Oedema • Scarring

pseudoptosis

• Microphthalmous • Pthisis bulbi• Double elevator

palsy• Blepharospasm• Contralateral

proptosis• Enopthalmous

History

• History of present illness • Associated history• Past history • Family history

History

• History of present illness :age of onset

• Associated history duration• Past history one/both

eye• Family history variability vision

History

• History of present illness • Associated history : diplopia • Past history odynophagia• Family history muscle

weakness cardiac problem night blindness

History

• History of present illness • Associated history• Past history : trauma/ surgery • Family history contact lens lid edema allergy dry eyes previous ptosis surgery

History

• History of present illness • Associated history• Past history • Family history

evaluation of ptosis

• head posture,Eyebrow position, eyelid masses, inflammation, proptosis

• pupillary size, reaction, heterochromia

• Best corrected Visual Acuity: In infants, make sure infant can fix and follow light with each eye

• Cycloplegic Refraction

evaluation of ptosis• Strabismus Evaluation• Extraocular Muscles Motility: Note

paresis, paralysis of muscles• Bell’s phenomenon • Jaw-Winking Phenomena Evaluation• Corneal Sensitivity• Schirmer’s Test• Funduscopic Examination : Abnormal

retinal pigmentation

Bell’s phenomenon

evaluation of ptosis• Strabismus Evaluation• Extraocular Muscles Motility: Note

paresis, paralysis of muscles• Bell’s phenomenon • Jaw-Winking Phenomena • Corneal Sensitivity• Schirmer’s Test• Funduscopic Examination : Abnormal

retinal pigmentation

Marcus gunn jaw winking phenomenon

evaluation of ptosis• Strabismus Evaluation• Extraocular Muscles Motility: Note

paresis, paralysis of muscles• Bell’s phenomenon • Jaw-Winking Phenomena • Corneal Sensitivity• Schirmer’s Test• Funduscopic Examination : Abnormal

retinal pigmentation

In children

• Presence or absence of Lid fold • Head tilt• Iliff test

Measurements

• Vertical fissure height• Margin reflex distance• LPS action• Lid crease level• Lid level on down gaze

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

Grading of severity of ptosis

< or = 2mm : mild ptosis= 3 mm : moderate ptosis= or > 4 mm : severe ptosis

MRD• Margin-to-reflex distance 1 (MRD1) : is the

distance from the central pupillary light reflex to the upper eyelid margin with the eye in primary gaze.

• A measurement of 4 - 5 mm is considered normal.

• 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. 

MRD

• Margin-to-reflex distance 2 (MRD2) : is the distance from the central pupillary light reflex to the lower eyelid margin with the eye in primary gaze. . 

• The MRD1 plus the MRD2 should equal the palpebral fissure measurement

Levetor function

•  is the distance the eyelid travel from downgaze to upgaze while the frontalis muscle is held inactive at the brow.

• The normal levator function is between 13-17mm

• Lid excursion is a measure of the levator function. The frontalis action is blocked by keeping the thumb tightly over the upper brow and asking the patient to look up from down gaze and measuring the amount of upper lid excursion at the center of the lid.

Berkes method

Grading of levator action

< 4mm – poor levator function5-7 mm – fair levator function8-12 mm – good levtor function

Lid crease

• Position is the distance from the crease to lid margin

• Normal – 8 to 10mm in primary gaze• An absent lid crease is often accompanied

by poor levator function. • If a lid crease is present but is higher than

normal and if a deeper upper lid sulcus is found on that side, note these as signs of a levator aponeurosis disinsertion.

Phenyl ephrine test

• Patients with minimal ptosis (2 mm or less) should have a phenylephrine test performed in the involved eye or eyes

•   Either 2.5 or 10% phenylephrine is instilled in the affected eye or eyes.  Usually two drops are placed and the patient is reexamined 5 minutes later. 

• The MRD1 is rechecked in the affected and unaffected eyes .

• A rise in the MRDl of 1.5 mm or greater is considered a positive test.  This indicates that Müller's muscle is viable

Ice test

Investigation

• Serum acetylcholine receptor assay• Tensilon test• EMG• ECG• ERG• T3, T4, TSH

Surgical management

• Wait till 3-4 years of age• Pupil covered operate immeditely

Surgical management

Surgical management

Case 1

• A 25 year old man is seen in OPD 2 months after blunt trauma to right orbit. Examination is normal except for blepharoptosis in RE. Levator function is normal on bothsides and the patient states the eyelid positions were equal on both sides prior to injury. There is no enophthalmous, and the patient does not complain of diplopia.

Case 1

• CT scan to rule out orbital fracture• Tensilon test to rule out myasthenia• Surgical exploration and repair of

aponeurosis• Close observation

Case 2

EYE VITALS RE LE

VERTICAL FISSURE 10 7.5

MRD 1 +4 +1.5

LEVATOR FUNCTION 14 15

EYELID CREASE 8 12

SCHRIMER’S 10mm 10mm

Case 2

• Levator aponeurosis advancement• Blepharoplasty• Frontalis suspention• Levator muscle resection

Case 3

• A 10 year old girl has bulging and blepharoptosis of both upper eyelids and recurrent episodes of eyelid inflammation and swelling. The diagnosis is

• Dermatochalasis• Blepharochalasis • Steatoblepharon• blepharospasm