DR SHARJEEL PGR 2 EYE UNIT 2 MAYO HOSPITAL KEMU

Drooping

of upper eyelids An abnormally low position of the upper eyelids

Drooping

occurs because one of the upper lid retractors are defective Main retractor is levator palpebralis superioris muscle supplied by 3rd cranial nerve Muller muscle a smooth muscle is the relatively weak retractor that has got sympathetic nerve supply Frontalis also assists lid elevation.

History

Age at presentation Mode of onset Variability of ptosis during day

Fatigue Associated diplopia Constitutional symptoms

Bell

s phenomena Levator function Fatigue test Margin reflex distance Jaw winking Upper lid crease Palpebral fissure height

According

to the cause

Depends

on levator function If near normal then levator advancement/reinsertion Mild ptosis Fasanella Servat procedure Moderate to severe ptosis- levator resection according to degree of ptosis Absent function- Frontalis suspension.Autogenous fascia lata or synthetic materials

PSEUDOPTOSIS CONGENITAL ACQUIRED

A

false impression of ptosis can be due toLack of support of the lids by the globe due to orbital volume deficit Enophthalmos Phthisis Bulbi Microphthalmos

1.

Contralateral eye 1.lid retraction 2.hypertropia 3. Ipsilateral hypotropia2. Because upper lid follows the globe downwards

4. Dermatochalasis Can also cause mechanical ptosis

Phthisis bulbi is an end-stage ocular response to sever ocular disease, inflammation, or insult

Abnormally small eye since birth

Posterior dislocation of the eye ball Can be congenital or acquired as in this case traumatic enophthalmos due to blow out fracture

Thyroid eye disease in this case

Simple

Myopathic Blepharophimosis syndrome Marcus Gunn Jaw Winking syndrome Ptosis with elevator palsy

Developmental

dystrophy of levator

muscle Absent lid crease Reduced levator function Lid lag on downgaze(levator stiffness) Superior rectus or double elevator dysfunction may be associated Rarely can be due to damage to aponeurosis due to birth trauma

Amblyopia

is present in 20 % cases A.visual axis obscuration B.strabismus C.anisometropia D.high astigmatism

Jaw

movements elevate the ptotic lid Congenital neurogenic ptosis Aberrant connections between cranial nerve 3 & 5 Contraction of pterygoid muscle elevates lid

APONEUROTIC MYOGENIC NEUROGENIC MECHANICAL TRAUMATIC

Most

common acquired ptosis Age related Thinning or disinsertion of levator aponeurosis Disinsertion from tarsal plate causes retraction of aponeurosis Findings are thinner upper lid ,higher upper lid crease,deep sulci,near normal levator function and absent lid lag on downgaze

At

the level of muscle itself

Myotonic dystrophy Chronic progressive external ophthalmoplegia At

the neuromuscular junction

Myasthenia gravis

Part

of inherited muscular dystrophies and the most common form that appear in adulthood Two types type 2 is milder There is progressive muscle wasting and weakness Bilateral symmetrical progressive ptosis Christmas tree cataract Myopathic facies Cardiac conduction abnormalities After sustained upward gaze they show inability to lower eyes for several seconds

Bilateral

symmetrical progressive ptosis Involvement of other EOMs limit motility and cause diplopia Kearns sayers syndrome if pigmentary retinopathy and cardiac conduction defects

Autoimmune

disorder Antibodies to acetylcholine receptors Start from small finework muscles Fluctuating ptosis is the characteristic presentation Easy fatiguability Sleep test Tensilon test Can mimick any palsy

Ptosis

and diplopia Never involves pupil Cogan twitch sign Ice pack test

3RD

Nerve Paralysis Horner s syndrome

Vasculopathic

causes

Diabetes Hypertension Atherosclerosis Sudden onset Pupil sparing Recovery within 3-6 months

Compressive

causes

Aneurysms Neoplasms Total or partial 3rd nerve palsy Progressive symtoms Pupil involved Emergency workup

Ptosis Eyeball

down and out Only abduction and intorsion possible Accomodation absent Fixed dilated pupil(efferent defect)

Mild

ptosis Normal pupil reactions Miosis Anhydrosis

Intracranial

tumours aneurysms and inflammation Pancoast tumour,carotid aneurysms

After

orbital injury Any injury to levator muscle nerve

Traumatic third nerve palsy that is recovering in a 15-year-old is shown here. Note mild ptosis in primary. It increases in right gaze (no third nerve innervation) but the lid widens even more than normally in left and down gaze suggesting aberrant innervation from the medial and inferior recti. Ptosis is minimal in up gaze. This can occur in traumatic third nerve palsy because of abnormal healing in the nerve bundle. Aberrant regeneration also occurs in congenital third nerve palsy suggesting a traumatic origin.

Chalazian Plexiforn

neurofibroma Any progressive growing mass in upper lid