Download classification of ptosis

CLASSIFICATION OF
PTOSIS
N.İREM ABDULHAYOĞLU
• Blepharoptosis or ptosis is defined as drooping
of the upper eyelid.
• Can affect all age groups and may be congenital
or acquired.
Anatomy
• The muscles responsible for eyelid retraction:
1. Levator palpebrae superioris; under voluntary
control from CN III.
2. Müller's muscle; contributes 1-2 mm of eyelid
elevation and it is under sympathetic
innervation.
3. Frontalis muscle; lifts the brows and is a minor
contributor to eyelid retraction and it is
innervated by CN VII.
Classification
A. Congenital
B. Acquired
1.Neurogenic
2.Myogenic
3.Aponeurotic
4.Mechanical
C. Pseudoptosis
A.Congenital Ptosis
• Simple congenital ptosis
▫ weakness of levator muscle
▫ most cases are this type when patient born with this
problem
▫ most often sporadic but can be inherited
• Congenital ptosis with weakness of superior
rectus muscle
▫ (the muscle that makes the eyeball look up)
▫ about 1 in 20 cases have the added eye muscle weakness
• Ptosis with blepharophimosis syndrome
▫ dominant hereditary condition
• Synkinetic ptosis
▫ involuntary motion of eyelid with attempted desired motion
▫ Marcus-Gunn jaw winking ptosis
▫ misdirected 3rd nerve ptosis
Blepharophimosis syndrome(BPES)
• narrowing of the eye opening (blepharophimosis)
• droopy eyelids (ptosis)
• upward fold of the skin of the lower eyelid near the inner
corner of the eye (epicanthus inversus)
• increased distance between the inner corners of the eyes
(telecanthus)
Marcus Gunn jaw-winking syndrome
(Congenital Trigemino-oculomotor synkinesis)
• Characterized by eyelid synkinesis with jaw
movement.
• Accounts for about 5% of all cases of congenital
ptosis.
B.Acquired Ptosis
1. NEUROGENIC PTOSIS
• Oculomotor nerve palsy
• Horner’s syndrome
• Myasthenia gravis
• Synkinetic ptosis
• Guillain-Barré syndrome
• Cerebral ptosis
• Botulism
Oculomotor nerve palsy
• Characterized by a variable degree of ptosis
associated with deficits of adduction, elevation,
and depression of the eye due to weakness of the
levator muscle, the superior, inferior and medial
rectus muscles and the inferior oblique muscle.
• Palsy may be caused by neoplastic,
inflammatory, vascular or traumatic lesions.
• Patients may present with any combination of
ptosis, ophthalmoplegia, diplopia, and a poorlyreactive dilated pupil.
Horner's syndrome
(oculosympathetic paresis)
•
•
•
•
Ptosis (1-2mm)
Miosis
Facial anhidrosis
Enophtalmos
Damage anywhere along the sympathetic pathway;
-first order neurons (hypothalamus to spinalcord)
- second order neurons (spinal cord to superior
cervical ganglion)
-third order neuron (superior cervical ganglion to
orbit)
Myasthenia gravis
• In 85% of patients with myasthenia, the initial
symptoms were either ptosis or diplopia.
• Bilaterally or unilaterally
• Ptosis can change on a minute-to-minute basis.
Classically the ptosis is more severe in the
evening.
• Cogan's lid twitch: rapid saccades from
downgaze to the primary position may provoke
an overshoot of the upper eyelid.
• Tensilon test(edrophonium chloride): Tensilon
is a short acting anticholinesterase agent and it
will temporarily overcome the muscle weakness
2. MYOGENIC PTOSIS
•
•
•
•
Congenital dystrophy of the levator muscle
Myotonic dystrophy
Chronic progressive external ophtalmoplegia
Traumatic
Myotonic dystrophy
• A defining feature of the disease is myotonia, or
a failure of the muscle to relax.
• Eventually leads to facial and peripheral muscle
weakness.
• Christmas tree cataracts
• Frontal balding
• Intellectual impairment
Chronic progressive external
ophthalmoplegia (CPEO)
• Mitochondrial myopathy
• Symmetric, bilateral ptosis and
ophthalmoparesis typically in their 30's
• Kearns-Sayre syndrome : CPEO and retinitis
pigmentosa
3. APONEUROTIC PTOSIS
Defects in the levator aponeurotic
linkage(between the levator muscle and the tarsal
plate) in the presence of a normal functioning
muscle.
• Involutional(senile)
• Postoperative
• Post eyelid trauma
• Post eyelid edema
• Post contact lens wear
Involutional ptosis
•
•
•
•
•
Ptosis that is constant in all position of gaze
Lid drop on downgaze
Good levator function
High skin crease
Thinning of the eyelid
4. MECHANICAL PTOSIS
Due to excessive weight on the upper lid;
• Eyelid tumors
• Orbital lesions
• Cicatrizing conjunctival disorders
C.Pseudoptosis
The eyelid appears to be lowered but there is no
pathology of the eyelid muscles or aponeurosis.
• Contralateral eyelid retraction
• Hemifacial spasm
• Dermatochalasis(an excess of skin in the upper
eyelid)/brow ptosis
• Aberrant reinnervation of the facial nerve
• Double elevator palsy
REFERENCES
• Oculoplastic Surgery - Brian Leatherbarrow
• Göz Hastalıkları - Gerhard K. Lang
• https://www.aao.org/eyehealth/diseases/ptosis-treatment
• http://webeye.ophth.uiowa.edu/eyeforum/tutor
ials/ptosis/index.htm
Thank you…