Ptosis Flashcards
What is “normal” eyelid position in pp?
- Upper lid margin just covers the upper cornea
- 2mm below upper limbus
- Lower lid margin lies just below the cornea
- Contracted OO and relaxed LPS when eyes closed; vice versa when open
What do we want to investigate in a ptosis?
- Orthoptic investigation
VA ? AHP
CT ? Facial asymmetry
BSV
OM
Pupils - What is the diagnosis?
- Unilateral / bilateral?
- What effect does the ptosis have
vision / ocular alignment / BSV - Is the ptosis associated with any OM defect?
- Is the ptosis causing symptoms?
- Will it change the management plan
What do we need to observe & document of a ptosis?
- How much is the lid covering the eye?
- Lid position
relation to pupil
relation to CR - sl / sm / mod / mkd
- Observe frontalis overaction
How do you measure palpebral fissures?
- Distance between upper & lower lid margins
- Primary position
- Compare R & L
- Interpreting results:
lower lid position
unilateral ptosis
How do we measure marginal reflex distance?
Marginal reflex distance = the distance between the CR & upper lid margin
How do we investigate levator function?
- Pressure on brow - prevent frontalis action
- Measure excursion of lid between down & up gaze
- mm
normal > 15mm
good > 12mm
fair 5-11mm
poor < 4mm
How do we investigate ptosis on downgaze?
- Describe lid position on downgaze
- Can measure (mm)
- Lid lag on downgaze - dystrophic levator muscle
congenital ptosis - Levator unable to relax properly when looking down
- If levator not dystrophic - lid remains ptotic in all positions
How do we measure skin crease in ptosis?
- Skin crease formed by insertion of levator aponeurosis
- Can observe & describe lid crease
- Can measure (mm) when patient looking down
- Normal M = 8mm, F = 10mm
- Distance between upper lid margin & upper lid horizontal skin crease, when looking in
Primary position
Downgaze
What is really important to pay attention to in orthoptic investigation of a ptosis?
- VA
- AHP
- CT
- BSV
- OM
What did Griepentroa and Mohney (2014) find about ptosis?
Strabismus was found in 18.7% of patients with childhood ptosis
What are we looking for in a fundus check of a ptotic individual?
Looking for dual pathology and syndromes
Refraction - astigmatism / anisometropia
Fundus check
Kearns-Sayre syndrome
mitochondrial myopathy
pigmentary retinopathy
Retinal dystrophy
During OM’s of someone with a ptosis what must we make note of?
SR function
jaw winking
variability
Cogan’s lid twitch
aberrant movements
pupils
lid on downgaze
epicanthus
facial features
facial asymmetry
lid closure
Bells phenomenon
What are the categories of ptosis?
- Myogenic
- Neurogenic
- Mechanical
- Aponeurotic
What is a myogenic ptosis and what are some examples?
Due to a defect of the levator muscle
MG
- Variability
- Ptosis most common presenting feature
Myotonic dystrophy
Ocular myopathies
- CPEO
- Progressive limitations of OM & ptosis
Congenital ptosis
- Dystrophic levator muscle
- Most common ptosis in childhood
- Amount of levator function important
- Can be associated with SR weakness
What is Kearns Sayre Syndrome (simply)?
- Mitochondrial DNA deletion syndrome
- Onset of symptoms <20 years old
- Pigmentary retinopathy
- Progressive ophthalmoplegia & ptosis - bilateral
- Other symptoms: cardiac / neurological
What is Blepharophimosis Syndrome?
A Myogenic ptosis cause
- Ptosis, telecanthus, epicanthus inversus
- AD inheritance
- Strabismus & refractive error common
ET>XT>HT - May have nystagmus
- Amblyopia common
bilateral & unilateral
What is a neurogenic ptosis and what are some examples of this?
- Defect in the nerve supplying the levator muscle
- Superior division 3rd CN
3rd N palsy
- ? aberrant regeneration
Horners syndrome
- Ptosis, miosis, anhydrosis
- 2mm ptosis
Marcus Gunn jaw winking syndrome
- 5% congenital ptosis cases
- Ptosis elevates on jaw opening
- Ptosis elevates on jaw deviation to contralateral side
What is a mechanical ptosis and some examples of this?
- Something increasing the weight of the upper lid
E.g.
capillary haemangioma
neurofibroma
lid lesion
fat / oedema - Scar tissue limiting eyelid movement
Post op
chemical burn - Trauma to levator complex
birth trauma (?delivery with forceps)
What is aponeurotic ptosis?
- Weakness in the levator aponeurosis
- Restricts transmission of force from normal levator muscle to the upper lid
- Generalised stretching
- Localised dehiscence
(the breaking open of a wound that is partially healed,
usually after Sx) - Good levator function
- High upper lid crease
- No lid lag on down gaze
- Commonly involutional - age related degenerative change
- Bilateral ptosis
- Worse at end of day (not to be confused with MG)
What differential diagnoses do we need to consider in ptosis?
- Pseudo ptosis
The false appearance of ptosis
hypotropia, enopthalmos, artificial eye, dermatochalasis - Hypotropic
In hypotropia lid position lower - lid covers the eye as it looks down
Hypotropia - crucial to observe & measure the ptosis when each eye is fixing in primary position
Pseudo ptosis & true ptosis may coexist
- Duane’s Syndrome
How do we manage ptosis initially?
- Amblyopia treatment (occlusion treatment may need to be more aggressive depending on type of amblyopia but don’t want to risk occlusion amblyopia)
- Refraction
- AHP
- Treat cause of ptosis e.g. steroid injections in capillary haemangioma
- Treat general health e.g. MG
What conservative management do we have in ptosis?
Ptosis props
- Adaptation to glasses
- Metal bar / loop to lift upper lid
- Unilateral / bilateral
may be only option
ptosis progressive / unsuitable for Sx
Paediatric patients may lift their own ptotic lid
finger / thumb
What must we consider in congenital ptosis before surgery?
- Usually delayed until can assess levator function
- Performed younger when risk of dense amblyopia
What are the surgical options in ptosis?
- Fascenella Servat
- Conjunctival-Muller’s muscle resection
- Levator aponeurotic repair
- Levator Resection
- Levatorpexy
- Brow Suspension
- Whitnall’s Ligament Sling
What happens in Fasenella Servat surgery?
- Upper border of tarsal plate, lower part of Mullers muscle, overlying conjunctiva - excised
- Levator aponeurosis not involved in this procedure
- Mild congenital ptosis (2mm)
- Ptosis with good levator function
>10mm - Horner’s syndrome
What happens in Conjunctival-Muller’s muscle resection?
- Dissection of the conjunctiva & Muller’s muscle
- Excision
- Attachment of the resected edge
What happens in levator aponeurotic repair surgery?
If aponeurosis is damaged - may be an apparent gap
- Stretching
- Dehiscence
Suture together the healthy edges of aponeurosis
What is levator resection surgery?
Resection of LPS
Graded resection
- Amount of ptosis
- Amount of levator function
Mod congenital ptosis
- Greater degree of ptosis
- Levator function 4-10mm
Disadvantage - increases lid lag on downgaze
What is Levatorpexy?
Advance & plicate posterior surface of levator
Plication = to fold
Don’t resect muscle
Congenital ptosis
Moderate levator function
Not poor levator function
What happens in Brow Suspension surgery?
Eyelid suspended from the brow & elevated by the frontalis muscle
Using autogenous fascia lata
- Synthetic materials - post op problems
ptosis recurrence
granuloma formation
- Donor fascia lata
young patients
Severe congenital ptosis
- <4mm levator function
- previous levator resection may have failed
Unilateral - produces asymmetrical results
May weaken / excise normal levator & perform bilateral surgery
Lid continues to lift until 3/12 post op, then stabilises
What is Whitnall’s Ligament Sling?
- Alternative to brow suspension
- Poor levator function
- Excise aponeurosis (anterior to Whitnall’s ligament)
- Suture ligament to tarsus
- Whitnall’s ligament then attached to orbital roof (region of trochlea & lacrimal fossa)
- ‘Internal sling’
- May elevate lid satisfactorily in primary position
- May cause unacceptable lid lag on down gaze
