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Dr. ADITHYA PHADNIS
 ORBIT, EYELIDS AND LACRIMAL SYSTEM-AAO
2015-16
 YANOFF,DUKER OPHTHALMOLOGY FOURTH
EDITION
 KANSKI CLINICAL OPHTHALMOLOGY EIGHT
EDITION
 ALBERT AND JAKOBIEC’S PRINCIPLES AND
PRACTICE OF OPHTHALMOLOGY THIRD
EDITION
 INRODUCTION
 HISTORY
 CLASSIFICATION
 DIFFERENCES
 EXAMINATION
 SURGERY
BLEPHAROPTOSIS: Inferior displacement of
upper eyelid
1857- Bowman described shortening of levator muller muscle
complex through a conjunctival incision
1883- Everbusch and Snellen reported anterior levator resection
1897-Motais and Perinaud described superior rectus suspension
1975- Jones published the successful repair of acquired ptosis by
levator aponeurotic reattachment or resection.
CONGENITAL
•.
ACQUIRED
•.
1.MYOGENIC
•SIMPLE
• BLEPHAROPHIMOSIS
•DOUBLE ELEVATOR PALSY
•COFS
•CPEO
•OCULOPHARYNGEAL
DYSTROPHY
•MUSCULAR DYSTROPHY
2. NEUROGENIC
•3RD NERVE PALSY
•HORNER’S SYNDROME
•MYASTHENIA GRAVIS
•MARCUS GUNN JAW
WINKING
3.APONEUROTIC
•INVOLUTIONAL
•POST TRAUMATIC
•BLEPHAROCHALAIS
•RECURRENT EDEMA
MECHANICAL
•DERMATOCHALASIS
•EYELID MASS
•ORBITAL MASS
•SCARRING
PSEUDOPTOSIS
•GLOBE MALPOSITION
•HYPOTROPIA
•CONTRALATERAL
EYELID RETRACTION
1.MYOGENIC
• SIMPLE
•BLEPHAROPHIMOSIS
•DOUBLE ELEVATOR PALSY
•COFS
•CPEP
•OCULOPHARYNGEAL DYSTROPHY
•MUSCULAR DYSTROPHY
•Dysgenesis of levator muscle
• Histopath- decreased / absent striated
muscle
Presence of fibrous/adipose
tissue
• Associations:
SIMPLE CONGENITAL PTOSIS
Poor
eyelid
movement
Paucity of
muscle fibres
Decreased/ no
functioning of
LPS
Lid lag
(A) Decreased levator muscle function occurs
along with an indistinct upper eyelid crease.
(B) The ptosis is exaggerated in upgaze
due to the poor function of the levator muscle.
(C) In downgaze, the ptosis is
reduced or absent because the fibrotic levator muscle cannot stretch.
a) b) c)
BLEPHAROPHIMOSIS SYNDROME
•TELECANTHUS+EPICANTHUS + POORLY DEVELOPED NASAL
BRIDGE+PTOSIS+HORIZONTAL SHORTENING OF PALPEBRAL FISSURE
•Sx for epicanthus-
•Sx for ptosis-(levator function poor)
DOUBLE ELEVATOR PALSY
Ptosis+ inability to supraduct ipsilateral eye
Levator function-poor
Introduction: Ptosis + ophthalmoplegia
 Clinical features:
Gene
Types:
TYP
E
PTOSIS GLOBE INHERITA
NCE
GENE COMME
NTS
1 B/L INFRADUC
TION
AD 12p11.
2-q12
CHIN UP
2 B/L EXOTROPIA AR 11q IRANIAN
/MID
EAST
3 VARIABL
E
VARIABLE AD 16q24.
2-24.3
VERTICA
L
LIMITAT
ION
4 U/L VARIABLE SPORADI
C
-
CLINICAL FEATURES
2. NEUROGENIC
•3RD NERVE PALSY
•HORNER’S SYNDROME
•MYASTHENIA GRAVIS
•MARCUS GUNN JAW
WINKING
• Introduction
•Pathophysiology
•Clinical features
•Tests
•Treatment
BEFORE AFTER
 CONGENITAL
 AQUIRED
 COMPONENTS
CONGENITAL AQUIRED
Ptosis
3.APONEUROTIC
•INVOLUTIONAL
•POST TRAUMATIC
•BLEPHAROCHALASIS
•RECURRENT EDEMA
 Most common form of ptosis
 Stretching or dehiscence of the levator
aponeurosis.
Upper lid
crease
BLEPHAROCHALASIS
MECHANICAL
•DERMATOCHALASIS
•EYELID MASS
•ORBITAL MASS
•SCARRING
DERMATOCHALASIS
PTOSIS DUE TO EYELID MASS
Ptosis
PSEUDOPTOSIS
•GLOBE MALPOSITION
•HYPOTROPIA
•CONTRALATERAL
EYELID RETRACTION
IPSILATERAL HYPOTROPIA
CONTRALATERAL LID RETRACTION
BROW PTOSIS
CORRECTION:Browpexy, direct brow lift,endoscopic or
pretrichial brow lift
•.
•BLEPHAROCHLASIS •DERMATOCHALASIS
•.
•BROW PTOSIS
CONGENITAL
MYOGENIC PTOSIS
ACQUIRED
APONEUROTIC PTOSIS
 Mild to severe
ptosis
 Poorly formed
 Reduced
 Lid lag
 Mild to severe
ptosis
 Higher than
normal or absent
 Near normal
 Eyelid drop
1.MRD 1
2.Upper
eyelid crease
3. Levator
function
4. Downgaze
1. HISTORY
 Age of onset
 Progression
 Family history
 Marked variability in degree of ptosis during day
 Diplopia
 Presence of dysphonia, dypnoea,dysphagia or proximal
muscle weakness
1. MARGIN REFLEX HEIGHT(MRD1, MRD2)
2. PALPEBRAL FISSURE HEIGHT
3. UPPER EYELID CREASE
4. LEVATOR FUNCTION
5. LAGOPHTHALMOS
1. Head position, chin elevation,brow position
and brow action-
2. Quantity and quality of tear film
3. Bell’s phenomenon
4. Corneal sensation
5. Synkinesis
6. Herring’ law
7. Position of ptotic eyelid in downgaze
7. Visual acuity
8. Extraocular muscle function
9. Pupillary examination
10. External examination
1. Visual field testing(untaped and taped)
2. Photography
3. Pharmacological testing
EYELID
EXCURSION
LEVATOR
FUNCTION
DEGREE OF
PTOSIS
SURGERY
0mm Absent Severe Frontalis suspension
1-4mm Poor Severe Frontalis suspension or
maximal ext levator
resection+tarsal resection
5-7mm Fair Moderate Ext levator resection
8-10mm Good Mild Ext levator resection
11mm Excellent Mild Internal conjunctival
muller’s muscle resection
Ptosis
Ptosis
Ptosis
Ptosis
Ptosis
Ptosis
Ptosis
Ptosis
 Overcorrection
 Eyelid Crease Abnormalities
 Lagophthalmos and Exposure Keratitis
 Changes in Astigmatism
THANK
YOU

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