Lids 3 - Blepharoptosis Flashcards
Ptosis physiological features that aid diagnosis?
• Drooping of the upper lid Upper lid covers more than 2mm (one sixth) of the cornea
• Narrowing of palpebral fissure
• Raising of brows due to frontalis over-action
• Chin up head posture in bilateral ptosis
What are the Classifications if Pseudootosis?
•Enophthalmos
•Dermatochalasis
• Micro-ophthalmos
•Phthisis bulbi
•Hypotropia
• Contralateral eye; herrings law
- Eyelid retraction
What are the Classifications of Ptosis:
•Congenital
- Myogenic
- Neurogenic
•Acquired
- Aponeurotic
- Myogenic
- Neurogenic
- Traumatic
- Mechanical
Congenital Ptosis Classification and types in each classification:-
• Neurogenic
- Marcus Gunn Jaw winking ptosis
- Horners syndrome
•Myogenic
- Simple congenital Ptosis
Associated with superior rectus dysfunction
- Associated with a Syndrome (commonly BEPS)
Features of Myogenic Congenital Ptosis?
• Levator muscle
•Absent weak lid crease
• Lid lag on down gaze (levator is stiff muscle)
What does Superior rectus dysfunction cause?
• Causes poor/ absent Bell’s phenomenon
• Increases risk of exposure keratopathy with ptosis surgery
What is, Blepharophimosis Ptosis Epicanthus Inversus Syndrome, Or BPES?
• Associated with myogenic congenital ptosis
• Autosomal Dominant inheritance
• Blepharophimosis: decreased vertical Palpebral aperture
• Ptosis
• Epicanthus Inversus
• Telecanthus - Increased distance between medical canthi
Neurogenic Congenital Ptosis types?
•Marcus Gun Jaw winking Ptosis
• Congenital Horners syndrome
What is Marcus jaw winking ptosis?
•Causes a: Congenital neurogenic Synkinetic ptosis
• Aberrant connections between cranial nerves IlI and V (motor branches to pterygoids)
• Jaw movement (contraction of the pterygoid muscle) elevates the ptotic lid
What is Congenital Horners syndrome and its signs?
•Neurological syndrome that disrupts sympathetic nerve branch to eye.
Signs:-
• Mild Ptosis
• Miosis
• Heterochromia due to hypopigmentation of affected Iris
What defects are associated with congenital ptosis?
• Amblyopia is present in 20% with congenital ptosis
• Ptotic lid obscures visual axis causing:
- Anisometropia
- High astigmatism
- Strabismus
What is Aponeurotic acquired ptosis? And how does it present?
• Connection between levator palpebral connection to tarsal plate, via aponeurosis
•Most common
• Usually age related
• Thinning or disinsertion of levator aponeurosis
• Disinsertion from tarsal plate, causes retraction of aponeurosis
- Thinned upper lid, deep sulcus
- Higher upper lid crease (>8-10mm)
- Near normal levator function
- Absent lid lag on down gaze
What are the differences between Congenital Myogenic vs Acquired Aponeurotic ptosis regarding (severity, upper crease, levator function and eyelid on downgaze)?
•Congenital Myogenic
- Mild to severe ptosis
- Weak or absent upper crease
- Reduced levator function
- Eyelid lag on downgaze
• Acquired Aponeurotic
- Mild to severe ptosis
- Higher than normal upper crease
- Near normal levator function
- Eyelid drop on downgaze
Which levels can Myogenic acquired ptosis affect?
• At level of the muscle
- Myotonic dystrophy
- Chronic progressive external ophthalmoplegia (CPEO)
• At level of myoneural junction:-
- Myasthenia Gravis
(Ocular myasthenia)
Muscular Dystrophies 2 types and their associated signs?
• Myotonic Dystrophy
- Bilateral symmetrical progressive ptosis
- Christmas Tree cataract
- Myopathic facies
- Cardiac conduction abnormalities
• СРЕО
- Bilateral symmetrical progressive ptosis
- Involvement of other extraocular muscles
- Pigmentary retinopathy
- Cardiac conduction abnormalities
What is Myasthenia Gravis and its symptoms and signs?
• Autoimmune disorder
• Antibodies to acetylcholine receptors
Symptoms:
• Easy fatiguability
• Life threatening symptoms - dysphagia and dyspnoea
• Fluctuating ptosis characteristic presentation
Signs:
- Ptosis and diplopia
- Ptosis worsens on prolonged up-gaze
- Pupil always normal
- Consider myasthenia in every case of ptosis or diplopia
Myaesthenia Gravis - Diagnosis tests and treatment
• Tensilon (Edrophonium chloride) test is the classical diagnostic test to confirm diagnosis
- IV anti-acetylcholinesterase drug, ptosis improves on injection
• Other tests
- Ice pack test - improves ptosis
- Prolonged up-gaze - worsens
ptosis
- Rest/ sleep test - improves ptosis
•Anti cholinesterase drugs
• Corticosteroids
• Immunosuppressants
• Thymectomy
Adult Myogenic Ptosis cause and concern?
• Ptosis with reduced levator function
• Additional systemic abnormalities which need to be investigated
Acquired neurogenic cause and categories:
• 3rd nerve paralysis
- levator muscle
- Superior rectus
- Inferior rectus
- Medial rectus
- Inferior oblique
• Horners syndrome
Oculomotor nerve palsy:-
• Ptosis
• Eyeball down and out
• Only abduction and intorsion movements present
• Pupil may or may not be involved
• Accommodation absent
Acquired Oculomotor nerve palsy divisions and their possible causes:-
• Vasculopathic causes
- Diabetes
- Atherosclerosis
- Hypertension
• Compressive causes
- Aneurysm
- Neoplasm
Vasculopathic palsy presentation?
• Sudden onset
• Pupil sparing
• Recovery within 3-6months
Compressive nerve palsy presentation
• Total or partial
• Progressive symptoms
• Pupil involved
• Emergency workup
What causes Acquired horners syndrome: And what are the signs?
• Causes
- Intracranial aneurysm/tumour/inflammation
- Pancoast’s tumour/ carotid aneurysms/ malignant cervical lymph nodes
Signs:
• Mild ptosis as a rule
• Miosis
• Normal pupillary reactions
• Anhydrosis
Acquired - Traumatic causes:-
• Orbital injury
Mechanical acquired ptosis causes:
• Chalazion
• hordeolum
• Tumour
• Something “mechanically weighs down lid”
What are checked during slit lamp exam of Ptosis:-
• Measurement of ptosis:-
- Palpebral fissure height
- Marginal reflex distance
- upper lid crease and fold
- Levator excursion
• Always check EOM, pupils, synkinesis, dryness
Levator Function classification:-
(and how they are surgically managed)
•15mm - Normal
• Greater or equal 8mm - Good
- Mullers muscle - conjunctival resection MMCR
- Levator aponeurosis advancement
• 5-7mm - Fair
- Levator resection
• Less or equal to 4mm - Poor
- Frontalis brow suspension
