Strabismus & Ocular Motility > Ptosis > Flashcards

Ptosis Flashcards

(31 cards)

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1
Q

What is “normal” eyelid position in pp?

A
  • Upper lid margin just covers the upper cornea
  • 2mm below upper limbus
  • Lower lid margin lies just below the cornea
  • Contracted OO and relaxed LPS when eyes closed; vice versa when open
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2
Q

What do we want to investigate in a ptosis?

A
  • Orthoptic investigation
    VA ? AHP
    CT ? Facial asymmetry
    BSV
    OM
    Pupils
  • What is the diagnosis?
  • Unilateral / bilateral?
  • What effect does the ptosis have
    vision / ocular alignment / BSV
  • Is the ptosis associated with any OM defect?
  • Is the ptosis causing symptoms?
  • Will it change the management plan
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3
Q

What do we need to observe & document of a ptosis?

A
  • How much is the lid covering the eye?
  • Lid position
    relation to pupil
    relation to CR
  • sl / sm / mod / mkd
  • Observe frontalis overaction
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4
Q

How do you measure palpebral fissures?

A
  • Distance between upper & lower lid margins
  • Primary position
  • Compare R & L
  • Interpreting results:
    lower lid position
    unilateral ptosis
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5
Q

How do we measure marginal reflex distance?

A

Marginal reflex distance = the distance between the CR & upper lid margin

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6
Q

How do we investigate levator function?

A
  • Pressure on brow - prevent frontalis action
  • Measure excursion of lid between down & up gaze
  • mm
    normal > 15mm
    good > 12mm
    fair 5-11mm
    poor < 4mm
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7
Q

How do we investigate ptosis on downgaze?

A
  • Describe lid position on downgaze
  • Can measure (mm)
  • Lid lag on downgaze - dystrophic levator muscle
    congenital ptosis
  • Levator unable to relax properly when looking down
  • If levator not dystrophic - lid remains ptotic in all positions
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8
Q

How do we measure skin crease in ptosis?

A
  • Skin crease formed by insertion of levator aponeurosis
  • Can observe & describe lid crease
  • Can measure (mm) when patient looking down
  • Normal M = 8mm, F = 10mm
  • Distance between upper lid margin & upper lid horizontal skin crease, when looking in
    Primary position
    Downgaze
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9
Q

What is really important to pay attention to in orthoptic investigation of a ptosis?

A
  • VA
  • AHP
  • CT
  • BSV
  • OM
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10
Q

What did Griepentroa and Mohney (2014) find about ptosis?

A

Strabismus was found in 18.7% of patients with childhood ptosis

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11
Q

What are we looking for in a fundus check of a ptotic individual?

A

Looking for dual pathology and syndromes

Refraction - astigmatism / anisometropia

Fundus check
Kearns-Sayre syndrome
mitochondrial myopathy
pigmentary retinopathy
Retinal dystrophy

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12
Q

During OM’s of someone with a ptosis what must we make note of?

A

SR function
jaw winking
variability
Cogan’s lid twitch
aberrant movements
pupils
lid on downgaze

epicanthus
facial features
facial asymmetry
lid closure
Bells phenomenon

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13
Q

What are the categories of ptosis?

A
  • Myogenic
  • Neurogenic
  • Mechanical
  • Aponeurotic
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14
Q

What is a myogenic ptosis and what are some examples?

A

Due to a defect of the levator muscle

MG
- Variability
- Ptosis most common presenting feature

Myotonic dystrophy

Ocular myopathies
- CPEO
- Progressive limitations of OM & ptosis

Congenital ptosis
- Dystrophic levator muscle
- Most common ptosis in childhood
- Amount of levator function important
- Can be associated with SR weakness

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15
Q

What is Kearns Sayre Syndrome (simply)?

A
  • Mitochondrial DNA deletion syndrome
  • Onset of symptoms <20 years old
  • Pigmentary retinopathy
  • Progressive ophthalmoplegia & ptosis - bilateral
  • Other symptoms: cardiac / neurological
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16
Q

What is Blepharophimosis Syndrome?

Study These Flashcards
A

A Myogenic ptosis cause

  • Ptosis, telecanthus, epicanthus inversus
  • AD inheritance
  • Strabismus & refractive error common
    ET>XT>HT
  • May have nystagmus
  • Amblyopia common
    bilateral & unilateral
17
Q

What is a neurogenic ptosis and what are some examples of this?

Study These Flashcards
A
  • Defect in the nerve supplying the levator muscle
  • Superior division 3rd CN

3rd N palsy
- ? aberrant regeneration

Horners syndrome
- Ptosis, miosis, anhydrosis
- 2mm ptosis

Marcus Gunn jaw winking syndrome
- 5% congenital ptosis cases
- Ptosis elevates on jaw opening
- Ptosis elevates on jaw deviation to contralateral side

18
Q

What is a mechanical ptosis and some examples of this?

Study These Flashcards
A
  • Something increasing the weight of the upper lid
    E.g.
    capillary haemangioma
    neurofibroma
    lid lesion
    fat / oedema
  • Scar tissue limiting eyelid movement
    Post op
    chemical burn
  • Trauma to levator complex
    birth trauma (?delivery with forceps)
19
Q

What is aponeurotic ptosis?

Study These Flashcards
A
  • Weakness in the levator aponeurosis
  • Restricts transmission of force from normal levator muscle to the upper lid
  • Generalised stretching
  • Localised dehiscence
    (the breaking open of a wound that is partially healed,
    usually after Sx)
  • Good levator function
  • High upper lid crease
  • No lid lag on down gaze
  • Commonly involutional - age related degenerative change
  • Bilateral ptosis
  • Worse at end of day (not to be confused with MG)
20
Q

What differential diagnoses do we need to consider in ptosis?

Study These Flashcards
A
  • Pseudo ptosis
    The false appearance of ptosis
    hypotropia, enopthalmos, artificial eye, dermatochalasis
  • Hypotropic
    In hypotropia lid position lower - lid covers the eye as it looks down
    Hypotropia - crucial to observe & measure the ptosis when each eye is fixing in primary position

Pseudo ptosis & true ptosis may coexist

  • Duane’s Syndrome
21
Q

How do we manage ptosis initially?

Study These Flashcards
A
  • Amblyopia treatment (occlusion treatment may need to be more aggressive depending on type of amblyopia but don’t want to risk occlusion amblyopia)
  • Refraction
  • AHP
  • Treat cause of ptosis e.g. steroid injections in capillary haemangioma
  • Treat general health e.g. MG
22
Q

What conservative management do we have in ptosis?

Study These Flashcards
A

Ptosis props
- Adaptation to glasses
- Metal bar / loop to lift upper lid
- Unilateral / bilateral
may be only option
ptosis progressive / unsuitable for Sx

Paediatric patients may lift their own ptotic lid
finger / thumb

23
Q

What must we consider in congenital ptosis before surgery?

Study These Flashcards
A
  • Usually delayed until can assess levator function
  • Performed younger when risk of dense amblyopia
24
Q

What are the surgical options in ptosis?

Study These Flashcards
A
  • Fascenella Servat
  • Conjunctival-Muller’s muscle resection
  • Levator aponeurotic repair
  • Levator Resection
  • Levatorpexy
  • Brow Suspension
  • Whitnall’s Ligament Sling
25
What happens in Fasenella Servat surgery?
- Upper border of tarsal plate, lower part of Mullers muscle, overlying conjunctiva - excised - Levator aponeurosis not involved in this procedure - Mild congenital ptosis (2mm) - Ptosis with good levator function >10mm - Horner's syndrome
26
What happens in Conjunctival-Muller's muscle resection?
- Dissection of the conjunctiva & Muller's muscle - Excision - Attachment of the resected edge
27
What happens in levator aponeurotic repair surgery?
If aponeurosis is damaged - may be an apparent gap - Stretching - Dehiscence Suture together the healthy edges of aponeurosis
28
What is levator resection surgery?
Resection of LPS Graded resection  - Amount of ptosis - Amount of levator function Mod congenital ptosis - Greater degree of ptosis - Levator function 4-10mm Disadvantage - increases lid lag on downgaze
29
What is Levatorpexy?
Advance & plicate posterior surface of levator Plication = to fold Don’t resect muscle Congenital ptosis Moderate levator function Not poor levator function
30
What happens in Brow Suspension surgery?
Eyelid suspended from the brow & elevated by the frontalis muscle Using autogenous fascia lata - Synthetic materials - post op problems ptosis recurrence granuloma formation - Donor fascia lata young patients Severe congenital ptosis - <4mm levator function - previous levator resection may have failed Unilateral - produces asymmetrical results May weaken / excise normal levator & perform bilateral surgery Lid continues to lift until 3/12 post op, then stabilises
31
What is Whitnall's Ligament Sling?
- Alternative to brow suspension - Poor levator function - Excise aponeurosis (anterior to Whitnall's ligament) - Suture ligament to tarsus - Whitnall's ligament then attached to orbital roof (region of trochlea & lacrimal fossa) - 'Internal sling' - May elevate lid satisfactorily in primary position - May cause unacceptable lid lag on down gaze
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