PTOSIS

Ptosis is drooping of upper eye lid.

causes include congenital and acquired. 

Acquired causes include 

1. neurogenic 

   1. horner syndrome, 

   2. 3rd nerve paralysis), 

2. myogenic (myasthenia gravis, myotonic dystrophy)

3. aponeurotic and 

4. mechanical. 

some diseases present as pseudoptosis. They are 

1. hypotropic squint, 

2. dermatochalasis (excessive skin on lids)

3. ocular volume deficit such as enophthalmos, artificial eye, phthisical eye

4. and contralateral lid retraction. 

Assessment

History:

1. onset and duration of ptosis

2. old photographs

3. variability with time of day (myasthenia)

Examination

1. The most important test to evaluate ptosis is levator function. 

   1. normal >15, 

   2. good>12-15, 

   3. fair 5-11 

   4. and poor <4mm.

• žFirst we ask the patient to look down

• žIt is checked by placing a thumb over forehead thus negating the action of frontalis muscle

• žThen we ask the patient to loop up

• žThe excursion of upper lid from down gaze to upgaze is noted

Other tests done in ptosis evaluation are

2. MARGINAL REFLEX DISTANCE

žThe distance between ceMntral corneal reflex and upper lid margin when eyes are looking straight ahead with head erect position.

žMRD 1: 4 mm are normal

žMRD 2: when lid crosses  pupillary axis

3. VERTICAL PALPEBRAL FISSURE HEIGHT

žThe distance between upper and lower lid when patient looking straight ahead

žNormal 10 mm

4. LID CREASE

žIt is distance between upper lid margin and upper lid crease in primary position

žNormal lid crease 10 mm

5. PUPIL

Must be examined to rule out Horner sydrome

6. Fatigueability

Ask patient to look up for 30 second and look for eye drooping for myasthenia

Two important tests before going for surgery one should not forget are

BELLS PHENOMENON: Open none eye with hand and ask patient to close it. Eye ball going up show good bells

MARCUS GUNN JAW WINKING PHENOMENON: Ask patient to move his jaw from right to left or chew. blinking of ipsilateral eye occurs in positive tests.

Question: what are causes of Pseudoptosis

special investigation of Ptosis

1. tensilon test for myesthenia gravis

2. phenylephrine test for horner syndrome

3. neurological investigation for neurogenic ptosis

TREATMENT:

FASANELLA SERVAT PROCEDURE: Levator function is good and ptosis is mild 2 mm

lid is everted and upper border of tarsus along with attached muller muscle and conjunctiva are resected

LEVATOR RESECTION: If levator function is fair and ptosis is mild 2-4 mm

levator muscle is resected either from conjunctival or skin incision

amount of levator resection: 

minmal ptosis: 16-17 mm

moderate: 18-22 mm

severe: 23-24 mm

FRONTALIS SLING: if levator function is poor and ptosis is severe > 4mm

in this procedure lid is anchored to frontalis muscle by a sling.

facia lata or some nonabsorbable material like supramid or gortex may be used as sling

Complications of ptosis surgery

1. ¨Under correction

2. ¨Over correction

3. ¨Exposure keratopathy

Treatment of Marcus gunn jaw winking syndrome

unilateral levator disinsertion with ipsilateral brow suspension

bilateral levator disinsertion with bilateral brow suspension for symmetric result

treatment of aquired ptosis

find and treat the cause

in neurogenic ptosis initial management is conservative. surgery is deferred for 6 months.