1. CLASSIFICATION OF PTOSIS
1. Neurogenic
Third nerve palsy
Third nerve misdirection
Horner syndrome
Marcus Gunn jaw-winking syndrome
2. Myogenic
Myasthenia gravis
Myotonic dystrophy
Ocular myopathies
Simple congenital
Blepharophimosis syndrome
3. Aponeurotic
4. Mechanical

2. PTOSIS 1. Evaluation 2. Classification 3. Treatment options
Pseudoptosis
True ptosis
2. Classification
Neurogenic ptosis
Myogenic ptosis
Aponeurotic ptosis
Mechanical ptosis
3. Treatment options

3. Causes of pseudoptosis
Contralateral lid retraction
Lack of lid support
Ipsilateral hypotropia
Brow ptosis - excessive
eyebrow skin
Dermatochalasis - excessive
eyelid skin

4. Marginal reflex distance
Distance between upper lid
margin and light reflex (MRD)
Mild ptosis (2 mm of droop)
Moderate ptosis (3 mm)
Severe ptosis (4 mm or more)

5. Upper lid excursion Reflects levator function Normal (15 mm or more)
Good (12 mm or more)
Fair (5-11 mm)
Poor (4 mm or less)

6. Vertical fissure height
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

7. Upper lid crease Pretarsal show Distance between lid margin and lid
fold
crease
Distance between lid margin and lid
crease in down-gaze
Distance between lash line and skin fold
in primary position of gaze
Normals - females 10 mm; males 8 mm
Absence in congenital ptosis indicates
poor levator function
High crease suggests an aponeurotic
defect

8. Bell’s phenomenon Upward rotation of globe on lid closure Good
Poor - risk of postoperative
corneal exposure

9. Left third nerve palsy Severe unilateral ptosis and Normal abduction
defective adduction
Defective elevation
Defective depression

10. 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 primary
position
Worse on right gaze
Normal on left gaze

11. Horner syndrome Caused by oculosympathetic palsy
Usually unilateral mild
ptosis and miosis
Normal pupillary reactions
Slight elevation of lower lid
Iris hypochromia if
congenital or longstanding
Anhydrosis if lesion is below
superior cervical ganglion

12. Posterior hypothalamus (second order neurone)
Important causes of Horner syndrome
Central
(first order neurone)
Posterior hypothalamus
Brainstem disease
(vascular, demyelination)
Spinal cord disease
(syringomyelia, tumours)
Pre-ganglionic
(second order neurone)
Superior cervical
ganglion
Intrathoracic lesions
(Pancoast tumour, aneurysm)
Neck lesions
(glands, trauma)
Post-ganglionic
(third order neurone)
Internal carotid artery disease
Ciliospinal centre of
Budge( C8 - T2 )
Cavernous sinus mass

13. 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

14. Myasthenia Gravis 1. Clinical features 2. Investigations
Uncommon, typically affects young women
Weakness and fatiguability of voluntary musculature
Three types - ocular, bulbar and generalized
2. Investigations
Edrophonium (Camiston) test
Electromyography to confirm fatigue
Antibodies to acetylcholine receptors
CT or MRI for presence of thymoma
3. Treatment options
Medical - anticholinesterases, steroids and azathioprine
Thymectomy

15. Ocular myasthenia Ptosis Diplopia
Insidious, bilateral but asymmetrical
Intermittent and usually vertical
Worse with fatigue and in upgaze
Ptotic lid may show ‘twitch’ and
‘hop’ signs

16. Edrophonium test Before injection Positive result
Measure amount of ptosis or
diplopia before injection
Inject i.v. test dose of edrophonium
(0.2 ml-2 mg)
Inject remaining (0.8 ml-8 mg) if no
hypersensitivity
Inject i.v. atropine 0.3 mg

17. Myotonic dystrophy Facial weakness and Release of grip difficult
ptosis
Release of grip difficult
Muscle wasting
Hypogonadism
Frontal baldness in males
Involvement of tongue and pharyngeal muscles
Intellectual deterioration
Ophthalmoplegia - uncommon
Presenile stellate cataracts

18. Ocular myopathies Ocular features Clinical types Isolated
Ptosis - slowly progressive and
symmetrical
Oculopharyngeal dystrophy
Ophthalmoplegia - slowly
progressive and symmetrical
(no diplopia)
Kearns-Sayre syndrome
(pigmentary retinopathy)

19. 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

20. Blepharophimosis syndrome
Rare congenital disorder
Dominant inheritance
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

21. Aponeurotic ptosis Mild Severe Weakness of levator aponeurosis
Causes - involutional, postoperative and blepharochalasis
Mild
High upper lid crease
Good levator function
Severe
Absent upper lid crease
Deep sulcus

22. Mechanical ptosis Causes Dermatochalasis Large tumours
Severe lid oedema
Anterior orbital lesions

23. 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

24. Levator resection
Indicated for any ptosis provided levator function is at least 5 mm
Shortening of levator complex
Amount determined by levator
function and severity of ptosis

25. Frontalis brow suspension
Main indications
Severe ptosis with poor levator function ( 4 mm or less )
Marcus Gunn jaw-winking syndrome
Attachment of tarsus to frontalis muscle with sling