1. Clinical Evaluation Of Ptosis
Md . Azizul Islam
Junior Optometrist
Oculoplasty Department (IIEI&H)
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2. DEFINITION
Abnormal drooping of upper eyelids is called
ptosis.
Normally upper eyelid covers 2mm of cornea.
Therefore in ptosis it covers more than 2mm.
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3. CLASSIFICATION OF PTOSIS
A. Congenital
B. Acquired
I. Neurogenic
II. Myogenic
III. Mechanical
IV. Traumatic
C. Pseudotosis
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4. Congenital ptosis
It is associated with congenital weakness (maldevelopment)
of the levator palpebral superior (LPS) muscle.
1.Simple congenital ptosis :
Not associated with any other anomaly.
congenital ptosis with associated weakness of superior
rectus muscle.
2.Blepharophimosis syndrome:
which comprises congenital ptosis, blepharophimosis,
telecanthus and epicanthus inversus .
3.Congenital synkinetic ptosis :
(Marcus Gunn jaw winking pheno menon).
Its the condition of misdirection 3rd nerve , retruction of the
upper lid with various ocular movements.
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6. 3.Mechanical ptosis
Due to excessive weight on the upper lid
lid tumours,
multiple chalazion .
lid oedema.
4.Traumatic ptosis:
Trauma to levator muscle, post surgies.
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8. PSEUDOPTOSIS
Pseudoptosis is the appearance of
ptosis in the absence of levator
abnormality.
Exclude pseudoptosis (simulated
ptosis) on inspection.
Its common causes are:
Microphthalmos,
Anophthalmos,
Endophthalmos
Phthisis bulbi.
Double elevator palsy
Blepharospasm
Contralateral proptosis
Due to phthisis Bulbi
Due to Contralateral proptosis
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9. HISTORY
Ptosis
Age of onset
Duration
One/both eye
Diurnal variability
Associated history :
Diplopia
Fatigability
Variable
Muscle weakness
Vision
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10. Association with
Jaw movements
Abnormal ocular movements
Abnormal head posture
History of
Trauma or previous surgery
Poisoning
Use of steroid drops
Any reaction with anesthesia
Bleeding tendency
Previous photographs may prove to be of great
help.
Is there a family history of ptosis or of other
muscle weakness?
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11. This is a test for determining corneal reflex, if the
eyes are in alignment, You shine a light at the eyes
and observe where the light reflex is located in
reference to the pupil. Its may Central , Eccentric ,
In ward , Out ward.
HB / CL Reflex
Measurments of Ptosis
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12. Upper lid crease
• Distance between lid margin and lid
crease in down-gaze.
• Normal-females 10 mm; males 8 mm.
• Absence in congenital ptosis indicates
poor levarator function.
Distance between lash
line and skin fold in
primary position of
gaze.
Pretarsal show
crease fold
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13. Measurements Of MRD
Margin-reflex distance
(MRD).
MRD1: distance between
upper lid margin and
CLR. N: 4-4.5 mm
MRD2: distance between
lower lid margin and
CLR. N: 5-5.5 mm
Mild ptosis (2 mm )
Moderate ptosis (3 mm)
Severe ptosis (4 mm or more)
(MRD)
Normal MRD
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14. Measurements LPSA
Levator Palpebral Supirior Action(LPSA)
• Place thumb against brow to stop frontalis
• Patient look down
• Then look up
• Measure with a ruler
• Results:
– >15mm: normal
– 12-14 mm: good
– 5-11 mm: fair
– <4 mm: poor
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15. Measurements PFH
Palpebral fissure height(PFH)
• Distance between upper and lower lid margin
• Normal:
– Women: 8-12 mm
– Men: 7-10 mm
N.B: Upper lid margin rests about 2mm below upper
limbus and Lower lid margin 1mm above lower
Limbus. So we determind amount of unilateral ptosis
by PFH. IIEI&H
17. Marcus Gunn jaw winking pheno-
menon (MJWP).
Its the condition of misdirection 3rd nerve ,
retruction of the upper lid with various
ocular movements
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18. Ocular Motility:
Importance in myogenic ptosis,
To R/O 3rd nerve palsy
presence of strabismus, especially vertical strabismus
entails that it be corrected prior to the correction of
the ptosis.
Visual acuity
Best-corrected visual acuity should be assessed to
record any amblyopia if present, especially in cases of
congenital ptosis.
Pupillary Examination:
To diagnosis Horner’s syndrome
Involvement in a case of third nerve palsy
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19. Documentation of ptosis
mesurements
HB –Reflex :Central , Eccentric , In ward , Out ward.
Lid Crease :10 mm / 8 mm.
MRD : mild 2 mm , moderate 3 mm, severe 4 mm.
LPSA : 15 mm normal,8-12 mm good,5-11 mm fair,
<4 mm poor.
PFH : 8-10, 7-9 mm
Bell’s phenomenon : Good, Poor.
Ocular motility : full, restricted.
MGJWP : + (ve), - (ve) .
Corneal sensitivity : Good, fair.
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22. TREATMENTS
Non-surgical – Rehabilitative crutch glasses
Surgical - Definitive Treatment
Decision making
When to operate Which
procedure
concern is cosmetic any age.
concern is amblyopia early surgery.
squint has to be operated first.
Blepharophimosis, telecanthus, epicanthus operated
first
Depends on levator
function + associated
anomaly
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23. Pre - oparative Ptosis Post oparative ptosis
Results of ptosis Sx
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