ptosis and pupils

ptosis

• levator muscle primary elevator of upper lip = failure to function = ptosis

• secondary elevators inc Muller muscle & frontalis muscle

congenital ptosis

• isolated simple ptosis - weakness of levator or w ipsilaterl SR muscle paresis

• blepharophimosis- inverse epicanthic folds, thickening & ptosis of lids, wide IPD

• congenital 3 CNP

• double elevator palsy

• Marcus Gunn jaw winking

• abberant regeneration

• congenital fibrosis

• periodic ptosis w cyclic oculomotor palsy

• transient neonatal MG

• congenital Horner’s

Acquired - ptosis

• myogenic

  • MG

  • muscular dystrophy

  • myotonic dystrophy

  • CPEO - chronic progressive external opthalmoplegia

  • myositis

  • senile

• neurogenic

  • 3rd CNP

  • aberrant regeneration of 3 or 7th nerve

  • Horners

  • drug induced e.g. BT

• Mechanical

  • SOL involving the lid

  • trauma

  • scar tissue

ptosis - DD

diagnosed from pseudoptosis

• ipsilateral hypoT

• ipsilateral enophtalmos

• ipsilateral microphthalmos

• ipsilateral pthsisi bulbi

• contralateral proptosis

• contralteral lid retraction

INV

CH

• Signs of ptosis, look at AHP, strabismus , pupil abnormality

• pt is asymptomatic if congenital

• if acquired - worse in evening or fatigue e.g. MG

• could have prev facial nerve palsy/ BT

Refraction

• ↑ myopia in congenital potsis

AHP

• chin elevation for low lid

VA

• unilateral ptosis = stimulus deprivation amblyopia - could cause aniso amblyopia

• 3RD CNP - blurred vision due to mydriasis

CT

• ↑ strabismus w mod ptosis

OM

• SR observation and see changes in diff position and jaw movement

• pupil examined for signs of miosis and mydriasisi

• assessment of lid position and levator function

• measure palpebral apperature

• levator function - compare degree looking up and down

• assess Bells phenomenon in pupil abnormalities

accommodation

• defective accom w 3rd CNP and horners syndrome

non orthoptic test

• general medical, muscle biopsy, radiology, photography, neurological

MX - PTOSIS

• correct RE & amblyopia

• observation - marcus gun often improves

• eliminate or join dip - w prism or occlusion

• treat cause of acquired condition & wait for recovery

surgical MX

• frontalis suspension

• levator transposition

sm degree - good levator function

• levator resection

large angle

• levator tuck

consider Bells phenomenon and lagothalmos before surgery

non surgical

• drugs

• ptosis props

• magnets

post op complications

• corneal exposure

• eye lid too high or too low post op

• lash eversion or ectrpoian

• defective skin crease

• conjunctival proplapse

lid retraction

• TED

• IR tethering

• ptosis of contralteral eye

• midbrain disease

mx

• BT to lower upper eyelid in cases of lid retraction

• muller muscle recession and transection of upper eye lid

pupil INV

CH

• pupil abnormality

• ptosis, strabismus, hetechromia, GH, disease

VA

• blurred w mydriasis

• ↑ depth of focus noticed w miosis

CT

• strabismus w pupil involving 3rd CNP

• ET seen w accom conv spasm

OM

• EOM pareses w 3rd CNP

• vertical gaze palsy - midbrain syndrome

Accom

• N normal miosis in response to accom

• absent reaction to light = LND

• accom defective w mydriasis

• ↑ depth of focus noticed w miosis

pupil size n reaction

• pupil size irregular due to posterior synechiae from trauma or ocualr inflammation

• anisocoria

• pupillary response to light stimulus

• general obs

swinging light test

• pt fix on distant object - prevent accom miosis- bright light shone

  • direct& consensual light