TYPES & CAUSES OF PTOSIS by Dr MAZHAR ALI

DEFINITION

• Ptosis is an abnormally low position of the upper lid which may be congenital or acquired

Typess

• Congenital1. Simple2. Complicated

• Acquired 1. Neurogenic2. Myogenic3. Aponeurotic4 Mechanical

Pseudoptosis

Congenital Ptosis

• Commonest form of ptosis• Usually bilateral / Heriditary • Due to defective development of LPS• Simple congenital ptosis is an isolated

abnormality

Congenital Ptosis• Complicated – when associated with

developmental abnormality of surrounding structures Associated Superior rectus palsyAbnormal synkineses – Marcus Gunn ptosisDystrophy of the LPS Blepharophimosis syndrome (Ptosis, horizontal shortening of palp aperture, epicanthus inversus, telecanthus lat ectropion of the lower lids)

Simple congenital ptosis• Developmental dystrophy of levator muscle• Occasionally associated with weakness of superior rectus

Unilateral or bilateral ptosis of varying severity

In downgaze ptotic eyelid is slightly higher

Frequent absence of upper lid crease Usually poor levator function

Marcus Gunn jaw-winking syndrome• Accounts for about 5% of all cases of congenital ptosis• Retraction or ‘wink’ of ptotic lid in conjunction with stimulation of ipsilateral pterygoid muscles

Opening of mouth Contralateral movement of jaw

Acquired Ptosis

• Usually unilateral

Types 1.Neurogenic – Third nerve paralysis or due to

reduced sympathetic innervation (Horner syndrome – ptosis, anhydrosis and miosis)

Left third nerve palsy

Severe unilateral ptosis anddefective adduction Normal abduction

Defective elevation Defective depression

Horner syndrome

• Caused by oculosympathetic palsy• Usually unilateral mild ptosis and miosis

• Slight elevation of lower lid

• Normal pupillary reactions

• Iris hypochromia if congenital or longstanding

• Anhydrosis if lesion is below superior cervical ganglion

Right third nerve misdirection• Rare, unilateral• Aberrant regeneration following acquired third nerve palsy• Pupil is occasionally involved• Bizarre movements of upper lid accompany eye movements

Right ptosis in primaryposition

Worse on right gaze Normal on left gaze

Acquired Ptosis

2. Myogenic – gradual onset, bilateral condition, symmetrical Myotonic dystrophyChronic progressive exophthalmoplegiaMysthenia gravis ( damage to acetyl-cholin receptor at postsynaptic membrane with presence of antiacetylcholine receptor antibodies)

Acquired Ptosis

Mysthenia Gravis-Symptoms – variableSigns – bilateral ptosis, increases by prolonged fixation or attempt to look up , external ophthalmoplegia – partial or completeConformation by edrophonium injection test

Ocular myasthenia

• Insidious, bilateral but asymmetrical• Worse with fatigue and in upgaze

Ptosis

• Intermittent and usually vertical

Diplopia

Edrophonium test

• 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

Before injection Positive result

Acquired Ptosis

Aponeurotic Ptosis Is involutional is due to weakness

or disinsertion of LPS aponeurosis from ant surface of tarsal plate High lid fold with good LPS function

Aponeurotic ptosis• Weakness of levator aponeurosis• Causes - involutional, postoperative and blepharochalasis

High upper lid crease Good levator function

Absent upper lid crease Deep sulcus

Mild

Severe

Acquired Ptosis

• Mechanical Ptosis –• ptosis is caused by the gravitational effect

of a mass or by scarring• Tumour or inflammation weight down the

lid

Mechanical ptosis

Causes

Dermatochalasis Large tumours

Severe lid oedema Anterior orbital lesions

Pseudoptosis• false impression of ptosis may be caused by the following• 1    Lack of support of the lids by the globe may be due

to an orbital volume deficit associated with an artificial eye

• 2    Contralateral lid retraction, •

3    Ipsilateral hypotropia causes pseudoptosis because the upper lid follows the globe downwards

• 4    Brow ptosis due to excessive skin on the brow, or 7th nerve palsy,

Causes of pseudoptosis

Ipsilateral hypotropia Brow ptosis - excessive eyebrow skin

Dermatochalasis - excessiveeyelid skin

Lack of lid support Contralateral lid retraction

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