CONGENITAL PTOSIS

EVALUTION AND
MANAGEMENT
DR.TARAKESWARA RAO.MS;
 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
•
 CONTD
• NEUROLOGIC:
• A. OCULOMOTOR NERVE
PALSY
• B.HORNERS SYNDROME
• C.MYASTHENIA
• APONEURITIC:
• A.INVOLUTIONAL
• B.POST TRAUMATIC
• C. CHRO. RECURRENT
OEDEMA
 CONTD,

• MECHANICAL:
• A.EYE LID MASS
• B.ORBITAL MASS
• C.SCARRING
• PSEUDOSIS:
• A.GLOBE MALFORMATION
• B.HYPOTROPIA
• C.CONTRALATERAL EYELID
RETRACTION
 THE CLASSIFICATION OF
CONGENITAL PTOSIS
CONGENITAL SIMPLE PTOSIS
WITH OCULOMOTOR ABNORMALITIES.
WITHBLEPHEROPHIMOSISSYNDROME
.SYNKINETIC PTOSIS.
MARCUS GUNN JAW WINKING.
 MISDIRECTED THIRD NERVE PTOSIS.
 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.
 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
 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.
 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 pto
 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.
 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.
 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.
 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.
 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
 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.
 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
 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.
 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.
 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.
 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
 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
 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.
Commonly performed surgeries

 levator resection
 fasanella servat operation

 brow suspensiON
 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
 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.
 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.