Ptosis Flashcards
What is ptosis
Drooping of the upper lid,
may be partial or complete
What conditions cause ptosis
Pseudo ptosis
3rd nerve palsy- sup division
Congenital
CFEOM
CPEO
Myastenia gravis
How can ptosis affect diplopia
The lid can be an occluder for the diplopia
What does the limbus mark
the transition between the cornea and sclera
When the eye is open in primary position….
upper lid margin just covers the upper cornea
2mm below upper limbus
lower lid margin lies just below the cornea
Some people – slightly above
Can palpebral fissure shape vary ethically
Yes
What is the mechanism when the eyelids close
The orbicular contracts
The levator palpebrae superioris relaxes
What is the mechanism when the eyelids open
The levator palpebrae superioris contracts
The orbicularis relaxes
What are the elevators of the upper eyelid
Levator palpebrae superiosis (LPS)
Mullers muscle
What supplies the LPS
Superior division on 3rd nerve
What supplies Mullers muscle
Sympathetic fibres
What connects the LPS and lid
Aponeurosis
What to document in ptosis patient
Unilateral / bilateral?
Facial asymmetry?
Head posture?
?Forehead creases
What type of AHP do ptosis children have and why
Chin elevation improves VA
What is the orthoptic investigation for ptosis
VA
CT
BSV
OM
Pupils
Can adults have congenital ptosis
YES
What are more specific qs about ptosis
Onset
Recent tx e.g. BT
Change
Signs
Symptoms
Variability
FH
GH
Can cosmetic botox cause ptosis
Yes it can leak into other muscles
What is the frontalis
The only muscle that raises the eyebrows
Children can use frontalis to elevate the lid
Frontalis can be used surgically to help with ptosis
How to record ptosis
Size
Which eye
How many 3rd of lid covered
Examples of ptosis recording
- Mrdk bilateral ptosis
R covering ¾
L slight ptosis - sl L ptosis using frontalis
What can the frontal compensate for
ptosis so comment if it is with to without frontalis muscle
What are the normal upper lid margin ranges
2mm below upper limbus
What are the normal lower lid margin ranges
1mm above lower limbus
What is marginal reflex distance
the distance between the CR & upper lid margin
Leavator function ranges
Normal: > 15mm
Good: > 12mm
Fair: 5-11mm
Poor: < 4mm
If there is lid lag on down gaze the levator is….
unable to relax properly when looking down so lid elevates (congenital ptosis)
What is a dystrophic levator muscle
lid lag on down gaze
What happens if levator not dystrophic
Ptosis in all positions
What is simple congenital ptosis
Developmental dystrophy of levator muscle. It’s occasionally associated with SR weakness
What is the skin crease formed by
insertion of levator aponeurosis
observe for pp and downsize
measure on down gaze
normal downgaze measurement
M- 8MM
F- 10MM
Use of AHP and what is a good sign for
trying to maintain BSV
maximising VA & VF (seeing under the ptosis)
bilateral ptosis
good sign for VA
What to observe in ocular movement testing
epicanthus
facial features
facial asymmetry
lid closure
Bell’s phenomenon
SR function
jaw winking
variability
Cogan’s lid twitch
aberrant movements
pupils
lid on downgaze
Why is fundus check important
There may be dual pathology and syndromes such as Kaern sayer which is a mitochondrial myopathy
What type of ptosis does Kaerns Sayer cause
Bilateral
Why does astigmatism cause ptosis
Due to pressure on cornea
What conditions can also have ptosis
MMAN
Myogenic
Neurogenic
Mechanical
Aponeurotic
What myogenic disorders cause ptosis
Due to levator muscle defect
MG, myotonic dystrophy, CPEO, congenital ptosis (SR weakness associated), Kaerns sayer, blepharophimosis syndrome
What is blepharophimosis syndrome
Ptosis, telecanthus, epicanthus inversus
AD inheritance
Strabismus & refractive error common
ET>XT>HT
May have nystagmus
Amblyopia common
(small eyes)
Telecanthus: eyes appear more widely spaced.
Epicanthus inversus: skin fold arising from lower inner eyelid.
What neurogenic disorders cause ptosis
Sup devision 3rd NP
Marcus Gunn
Horners (no swear on one side of face, miosis and ptosis)
What mechanical problems can cause ptosis
Something increasing weight of upper lid e.g. fat
Scar tissue e.g. post op or chemical burn
Trauma e.g. birth with forceps
What is aponeurotic ptosis
weakness in leaver aponeurosis which restricts transmission of force from normal levator muscle to upper lid
Common features of aponeurotic ptosis
good levator function
high upper lid crease
no lid lag on down gaze
bilateral ptosis
worse at end of day (not to be confused with MG)
Differential diagnosis
Pseudo ptosis (true can co exist)
Duanes
What is the management of ptosis
Amblyopia treatment
Treat the cause- steroids, propranolol oral
MG treatment- Prednisone, immunosuppressant
What are some conservative management options
Ptosis props
(adaptation to glasses
metal bar / loop to lift upper lid)
Paeds (lift lid with finger or thumb)
What are the surgical options and aims
FCLLLBW
AIM- improve position of upper lid margin
Fasenella Servat
Conjunctival-Muller’s muscle resection
Levator aponeurotic repair
Levator resection
Levatorpexy
Brow suspension (severe cong)
Whitnall’s ligament sling
How to assess surgical success
PP and downgaze
May have lid lag on downgaze so managing patient expectations is important
SUMMARY
Revise eyelid anatomy
Measure & document ptosis as accurately as possible
levator function
Differentially diagnose true ptosis & pseudo ptosis
Amblyopia treatment
challenging
can be successful
