1. Neurogenic
Third nerve palsy Third nerve misdirection Horner syndrome Marcus Gunn jaw-winking syndrome Myasthenia gravis Myotonic dystrophy Ocular myopathies Simple congenital Blepharophimosis syndrome
2. Myogenic
3. Aponeurotic 4. Mechanical
PTOSIS
1. Evaluation
Pseudoptosis True ptosis Neurogenic ptosis Myogenic ptosis Aponeurotic ptosis Mechanical ptosis
2. Classification
3. Treatment options
Causes of pseudoptosis
Ipsilateral hypotropia
Poor (4 mm or less)
Distance between upper and lower lid margins Normal upper lid margin rests about 2 mm below upper limbus Normal lower lid margin rests 1 mm above lower limbus Amount of unilateral ptosis is determined by comparison
Pretarsal show
fold
Distance between lid margin and lid crease in down-gaze Normals - females 10 mm; males 8 mm Absence in congenital ptosis indicates poor levator function High crease suggests an aponeurotic defect
Distance between lash line and skin fold in primary position of gaze
Bells phenomenon
Upward rotation of globe on lid closure
Good
Normal abduction
Defective elevation
Defective depression
Horner syndrome
Opening of mouth
Myasthenia Gravis
1. Clinical features
Uncommon, typically affects young women Weakness and fatiguability of voluntary musculature
2. Investigations
Electromyography to confirm fatigue Antibodies to acetylcholine receptors CT or MRI for presence of thymoma
Medical - anticholinesterases, steroids and azathioprine Thymectomy
3. Treatment options
Ocular myasthenia
Ptosis Diplopia
Insidious, bilateral but asymmetrical Worse with fatigue and in upgaze Ptotic lid may show twitch and hop signs
Edrophonium test
Before injection Positive result
Measure amount of ptosis or diplopia before injection Inject i.v. atropine 0.3 mg
Inject i.v. test dose of edrophonium (0.2 ml-2 mg) Inject remaining (0.8 ml-8 mg) if no hypersensitivity
Myotonic dystrophy
Release of grip difficult Facial weakness and ptosis
Ocular myopathies
Clinical types
Ocular features
Ptosis - slowly progressive and symmetrical Ophthalmoplegia - slowly progressive and symmetrical (no diplopia)
Blepharophimosis syndrome
Moderate to severe symmetrical ptosis Short horizontal palpebral aperture Telecanthus (lateral displacement of medial canthus) Epicanthus inversus (lower lid fold larger than upper) Lateral inferior ectropion Poorly developed nasal bridge and hypoplasia of superior orbital rims
Aponeurotic ptosis
Weakness of levator aponeurosis Causes - involutional, postoperative and blepharochalasis
Mild
Severe
Deep sulcus
Mechanical ptosis
Causes
Dermatochalasis
Large tumours
Fasanella-Servat procedure
Indicated for mild ptosis with good levator function
Excision of upper border of tarsus, lower border of Muller muscle and overlying conjunctiva
..
Levator resection
Indicated for any ptosis provided levator function is at least 5 mm
Main indications Severe ptosis with poor levator function ( 4 mm or less ) Marcus Gunn jaw-winking syndrome