1. CONGENITAL PTOSIS EVALUTION AND MANAGEMENT DR.TARAKESWARA RAO.MS;

2. Classification of Blepharoptosis CONGENITAL: 1.SIMPLE 2.COMLICATED ACQUIRED: 1.MYOGENIC A.DOUBLE ELEVATOR PALSY B.CHRONIC PROGRESSIVE EXTERNAL OPHTHALMOPLEGIA C.CONGENITAL OCULAR FIBROSIS D.MUSCULAR DYSTROPHY

3. CONTD NEUROLOGIC: A. OCULOMOTOR NERVE PALSY B.HORNERS SYNDROME C.MYASTHENIA APONEURITIC: A.INVOLUTIONAL B.POST TRAUMATIC C. CHRO. RECURRENT OEDEMA

4. CONTD, MECHANICAL: A.EYE LID MASS B.ORBITAL MASS C.SCARRING PSEUDOSIS: A.GLOBE MALFORMATION B.HYPOTROPIA C.CONTRALATERAL EYELID RETRACTION

5. THE CLASSIFICATION OF CONGENITAL PTOSIS  CONGENITAL SIMPLE PTOSIS  WITH OCULOMOTOR ABNORMALITIES.  WITHBLEPHEROPHIMOSISSYNDROME.SYNKINETIC PTOSIS. MARCUS GUNN JAW WINKING.  MISDIRECTED THIRD NERVE PTOSIS.

6. CLINICAL EVALUATION. IT IS BELIEVED THAT TRUE CONGENITAL PTOSIS OCCURS FROM DEVELOPMENTAL ANOMALY OF LEVATOR IN THE FORM OF LOCLIZED MUSCLE DYSTROPHY OF UNDETERMINED ETILOGY.

7. HISTORY THE FOLLOWING REVELANT HISTORY SHOULD BE ELICITED IN ALL PATIENTS OF PTOSIS TIME OF ONSET WHETHER INCREASING, DECREASING, CONSTANT SINCE THE TIME OF MANIFESTATION

8. ASSOCIATION WITH JAW MOVEMENTS ABNORMAL OCULAR MOVEMENTS ABNORMAL HEAD OSTUEP HISTORY OF TRAUMA OR PREVIOUS SURGERY ANY REACTION WITH ANAESTHESIA BLEEDING TENDENCY PREVIOUS PHOTOGRAPHS MAY PROVE TO BE OF GREAT HELP.

9. OCULAR EXAMINTION VISUAL ACUITY Best corrected visual acuity should be checked to record any amblyopia if present. Palpebral aperture: normal-9-10mm in primary gaze. Should be seen in up gaze down gaze and primary gaze Amount of ptosis- difference in palpebral apertures in unilateral ptosis or difference from normal in bilateral ptosis

10. Marginal reflex distance (MRD1)  normal 4-5mm  The light source is held directly in front of the patient looking straight ahead.the distance between the center of the lid margin of the upper lid and the reflex on the cornea would given the MRD1.if the margin is above the light reflex the mrd1 is a +ve value.if lid margin is below the corneal reflex in cases of severe ptosis the mrd1 would be a -ve value.

11. Amount of ptosis  The difference in mrd1 of the two sides in unilateral cases  or  The difference from normal in bilateral cases gives the amount of ptosis.

12. Grading of severity of ptosis  <or =2 mm : Mild ptosis  = 3mm:Moderate ptosis  =or >4mm: severe ptosis  It must be remembered that ptotic lid in unilateral ptosis is usually higher in down gaze due to failure of levator to relax.  The ptotic lid in acquired ptosis is lower than the normal lid in down gaze.

13. Levator function Berkes method—the frontalis action is blocked by keeping the thumb tightly over the upper brow and asking the patient to look up from down gaze and measuring the amount of upper lid excursion at the center of the lid.

14. PTOSIS Grading of levatorfunction <4mm—poor levator function 5-7mm—fair levator function 8—12mm—good levator function The normal levator function is 13—17mm

15. Putterman’s method This is carried out by the measurement of distance between the middle of upper lid margin to the 6o clock limbus in extreme up gaze. This is also know n as the marginal limbal distance normal is about 9mm. The difference in mld of two sides in unilateral cases or the difference with normal in bilateral cases multiplied by 3 would give the amount of levator resection required.

16. Marginal crease distance it is the distance between the center of upperlid margin to the lid crease The normal distance is between5—7mm and is measured in down gaze.it helps in planning the surgical incision. bell’s phenomenon : upward rotation of the eyeball on closure of the eye.presence of good bells phenonmenon is important.it must be confirmed before under taking any surgery

17. Corneal sensation The presence or absence of corneal sensation should be noted. ocular motility the extra ocular muscle functions should be recorded.specially the elevator muscles.any association of eye movements with change in the extent of ptosis should be looked for.

18. Phenylephrine test phenylephrine 10% drops are used to asses mild cases of ptosis. Positivephenylephrine test suggests that patient would respond well to hmullers muscle resection. Jaw movements the presence of jaw winking is assessed by moving the jaw from side to side,opening and closing the mouth.

19. Tensilon (neostigmine) test This test is done in doubtful cases where an acquired ptosis due to myasthania gravis is suspected. Traction test the lashes are held between the thumb and fore finger and traction applied.we look for the downward movement of the eyeball to rule out surgical or traumatic adhesion of upper lid with the globe.if the lid and the eye move independently no adhesion exists.

20. Timing of surgery Timing of surgery there should be no delay in surgicalmanagement incases of severe ptosis where pupil is obstructed.it may cause amblyopia.delay should alsobe avoided in cases of bilateral ptosis where chlid is likely to develop bad postural habits like head tilt brow wrinklingwhich are difficult to eradicate later. In these cases atemporary procedure may be opted for early and followed by definitive surgery later

21. Contd, if possible it is advisable to wait till 3-4years of age. The following advantages are achieved. -better assessment is possible. -tissues are better developed to withstand surgical trauma. -better post operative care is possible due to better cooperation

22. Choice of surgical procedure Choice is determined by -whether the ptosis is unilateral or bilateral. -severity of ptosis. -levator action. -simple ptosis or associated anomalies.

23. Commonly performed surgeries  levator resection  fasanella servat operation  brow suspensiON

24. INDICATIONS FOR THE CHOICE OF DIFFERENT SURGICAL PROCEDURES PTOSIS LEVATOR ACTI ON SURGERY MILD >10MM FASANELLA <10MM LEVATORRESECTION MODERATE GOOD LEVATORRESECTION FAIR LEVATORRESECTION POOR BROWSUSPENSION SEVERE FAIR BROWSUSPENSION POOR BROWSUSPENSION

25. MANAGEMENTOFCOMPLICATED PTOSIS WITH OCLOMOTORABNORMALITIES IN CASE WITH SUPERIOR RECTUS INVOLVEMENT I R RECESSION AT TIMES COMBINED WITH SR RESECTION IS CARRIED OUT ON THE AFFECTED SIDE AS THE FIRST PROCEDURE.TO CORRECT PTOSIS LEVATOR RESECTION WITH BILATERAL BROW SUSPESION IS DONE LATER.

26. DOUBLE ELEVATOR PALSY KNAPPS PROCEDURE MAY BE DONE FOR PTOSIS ASSOCIATED WITH DOUBLE ELEVATOR PALSY BLEPHAROPHIMOSIS SYNDROME ; MUSTARDES DOUBLE Z PLASTY OR YTOV PLASTY WITH TRANSNASAL WIRING IS DONE AS A PRIMARY PROCEDURE. BROW SUSPENSION IS CARRIED OUT 6 MONTHS AFTER THE FIRST PROCEDURE FOR CORRECTION OF PTOSIS.