Ptosis/pupils/lids

Ptosis - muscles inv

Muscles involved

-          Levator palpebrae superior – lps

o    Lifts upper eyelid

o    Controlled by CNIII

o    Dysfunction = true ptosis

-          Muller muscle

o    Secondary elevator

o    Sympathetically innervated – affected in Horner’s syndrome

-          Frontalis

o    Compensatory M – forehead m

o    Overused when ptosis present

o    Seen as raised eyebrows or forehead wrinkling

pseudo ptosis

Pseudo strabismus

-          Eyelid drooped not due to muscle weakness

Mimics inc

-          Enophthalmos - sunken eye

-          Microphthalmos – sm eye

-          Hypotropia

-          Proptosis

Ptosis inv

Inv

-          CH/AHP – chin elevation

-          OM – SR ua = CNIII

-          Pupil – mydriasis = CNIII

o    Miosis – horners

-          Levator = measure eyelid movement from up + down gaze

-          Bells phenomenon: upward eye movement w/ eye closure

-          Accommodation – affected in CNIII

Ptosis causes

Congenital

-          Weak or abnormal levator

-          can be:

o    simplified isolated ptosis

o    syndromic – blepharophimiosis

o    neurological – congenital CNIII, marcus Gunn

o    sx

Acquired

-          myogenic – MG, CPEO, myositis

-          neurogenic- CNPIII, Horner’s

-          mechanical – lid tumour, scarring, trauma

-          senile – age related, stretching of levator

-          tx underlying cause

CNIII: ptosis, mydriasis, EOM issue

Horner’s – mild ptosis + miosis

Ptosis mx

Mx

-          Correct RE _ amblyopia

-          Observation – MGJW improves

-          Remove dip – prism or occlusion

-          Tx cause of acquired + await recovery

Non surgical

-          Drugs

-          Ptosis props

-          Magnet

Sx

-          Sm dev c gd LPS function

o    Lps resection >5mm

-          Fasanella – servat

o    Excision of upper boarder of tarus + lower muller m

-          Brow suspension

o    Serve ptosis c poor LPS function – frontalis sling

o    MGJW. CPEO, belpharophlmosis

Post op complications

-          Corneal exposure

-          Eye lid too high/ low

-          Defective skin crease

-          Lash eversion

Ptosis - ent/ect

Entropion

-          Transverse suturing

-          Lower lid retractors

Ectropion

-          Tendon laxity

-          Temp       

o    Lubrication

o    BT to levator

Lid retraction

Lid retraction

-          Opposite to ptosis

Causes:

-          TED – IR tethering

-          Ptosis of contralat eye

-          Midbrain disease

-          MG

-          Iatrogenic

-          Dc

-          Parinauds

Tx

-          BT – temp relief – induce ptosis/ TED

-          Muller m sx

-          LPS recession

Pupils - functions/ size influence

Functions of pupil

-          regulate light

-          reduce spherical + chromatic aberration

-          increase depth of focus thru accom response

uniocular

o    Horner’s

o    anterior segment inflammation

-          Binoc

o    Argyl Robertson

o    Convergence/ accom response

Pupil size influence

-          Age

-          Light intensity

-          Drugs

-          Emotions

-          Hippus

mydriatic pupil – dilated

causes:

-          3^rd CNP

-          Holmes Aldie tonic

-          Dorsal midbrain - parinauds

-          Glaucoma

-          Trauma

-          Drugs

-          Hutchinson

Dorsal midbrain

-          LND

-          Convergence retraction nystag

-          Lid retraction

-          Causes: pineal gland, MS, hydrocephalus

-          Pupil accommodates – both react to light

-          Parasympathetic

Holmes adie tonic

-          Lesion in CG – bacterial viral infection

-          Women in 30/40s

-          Accom response impaired – N reduced

-          Poor light response

-          Reacts

o    Pilocarpine – 0.125%

o    Metacholine

o    Reduced knee jerk

3^rd CNP

-          Dialted pupil

-          Efferent PSF travel outer layer of 3^rd N

-          External compression on 3^rd N – pupil inv

 

Miotic pupil – constricted

Occur in light reflex + accom reflex

Horner’s syndrome

-          Ptosis – disseveration of muller m

-          Miosis – sm pupil

-          Anhidrosis – no sweating on affected side

Tests

-          Cocaine test – dilate normal pupil but not Horner’s

-          Paradine test – differentiate lesion site

-          Anisocoria increases in dim light  

Causes:

-          Trauma

-          Lung cancer

-          Spinal issues

-          Congenital defects

 

Argyll Robertson

-          Lesion in rostral midbrain affect reflex to EWS

-          Irregular miotic pupil + LND

-          Respond to N

-          Bilateral

Cause

-          Neurosyphilis

-          MS

Aberrant regeneration

• pupil constriction

• Adduction causes lid elevation.

• Adduction causes pupillary constriction.

• Elevation causes lid retraction.

Causes

• Compression by aneurysm or tumour.

• Head trauma

Relative afferent pupillary defect – RAPD

 

-          MGJW

-          Lesion in afferent pathway -e.g. retina// optic N

-          Tests: swinging light test

Grades

1.       Weak constriction – greater dilation

2.       No change – dilation

3.       Immediate dilation

4.       No reaction

Causes:

-          Optic neuropathy

-          Retinal detachment

-          TED

Pupils inv

Investigation

-          CT: check N/D + gls

-          PCT

-          OM: asses paresis vs mechanical

-          Ted, 3/4/6 Affect EOM

-          Hess

-          FDT

-          VF: goldmann or automated check for compressive lesion

-          Img – MRI, ms

-          CT: orbital, TED

Another test

-          ACH antibodies – MG

-          Neurological exam – stroke or CNO

-          Field of BSV

Irregular pupil/ neurological conditions

Irregular pupil

-          Trauma – posterior synechiae

-          Iris tumour - Correctopia

-          Coloboma – heterochromia

-          Anisocoria

Neurological conditions

-          Spasmus newton – nystagmus, head bopping, torticollis in children

-          OMA – ocular motor apraxia – lack of voluntary H eye movement

-          OCR – CNV – vagus – bradycardia

Pupil reflex/ triad

Pupil reflex

-          Retina – optic nerve – chiasm – pretectal nucleus

-          Bilateral EWS – CNIII – ciliary ganglion – sphincter

Near triad

-          Accommodation

-          Convergence

-          Pupilllary constriction

pupil - area 19

Area 19 of visual cortex

-          Neuron – visual cortex – LGB

-          Optic radiation – visual cortex – area 19

-          Cortical fibre – internal capsule – EWN – CNIII – sphincter

LND

LND

-          Aldie tonic

-          Parinauds

-          Argyll Robertson

-          aberrant regeneration

-          optic neuropathy

Parasympathetic

 

Parasympathetic

-          automatic control of pupil

-          miosis

-          pupil constriction

-          involves: inner circular muscles

-          triggers – light reflex + accommodation reflex

pathway

-          retina - optic N – optic chiasm – pretectal – EWS – oculomotor nerve – ciliary ganglion – iris sphincter = miosis

Sympathetic pathway

Sympathetic pathway

-          mydriasis

-          pupil dilation

-          involve – radial fibres

-          associated disorders

o    Horner’s syndrome

-          Pathway

o    1 ON – posterior hypothalamus – brainstem – C8 T2 – ciliospinal centre of budge

o    2 ON – preganglionic neuron – leaves spinal cord + enter – superior cervical ganglion

o    3^rd ON – post ganglion neuron – ICA – ophthalmic nerve - CS – orbit via – SOF – iris dilater – muller m

Diagnostic testing

Diagnostic testing

-          Observation – size, shape, symmetry

-          Tests

o    Swinging tests

o    Direct + consensual reflex

o    Near reflex

o    Look for – eyelid + eyelid position

o    Ask pt read down conv target see if pupil constricted – accommodation reflex

o    If nothing wrong – PERLA – pupil equal and reactive to light and accommodation

Aberrant regeneration

Aberrant regeneration

-          Eyelid retracts on add/ depression

-          Adduction of eye on elevation/ depression

-          Pupil constriction – adduction

-          Ptosis

-          Limited eye movements

-          FROM 3^RD NERVE = think AR

Lids - congenital

-          Congenital

o    Epiblepharon– extra skin folds

o    Congenital entropion- inward lid

o    Blepharophiomosis – ptosis, epicanthus inverse + flat nasal bridge

o    Simple ptosis – no lid crease – poor levator function

o    MGJW – ptosis varier with jaw movement

o    Congenital Horner’s – ptosis, miosis, heterochromia

o  Congenital fibrosis – restricted eye movement, ptosis, fibrotic EOM

Lids - acquired

Acquired

-          Entropion – lid turn inward

-          Extropian – lid turn outward

-          Lid lag – lid remain elevated during downgaze

-          Lid retraction

-          Lagophthalmos – incomplete lid closure

-          Belphatus – chronic lid margin inflammation

-          Bell’s palsy – orbicularis weakness

Lid examination

Lid examination

Tests

-          Levator function

o    Press brow + neutralise frontalis muscle

o    Measure pts eyes looking down to eyes looking up

-          Bells phenomenon

o    Check upward globe rotation during lid closure

-          Marginal reflex

o    MRD1 + MRD2

Synoptophore

-          9 positions of gaze

Non orthoptic test  

-          Photograph

-          Neurologic

-          Radiologic

-          Muscle biopsy

-          General med

Lids inv

Investigation

-          History – MG, trauma, thyroid

-          Observation – flutter, twitch, AHP

-          Lid change

-          CT – pseudo ptosis

-          OM – retraction, lid lag

-           AHP on movement

-          Lid elevation

-          Eyelid closure

Lids - mx

Mx

-          Medical

-          Lubricant – for exposure – ectropion

-          Lagophthalmos

-          BT – for lid retraction

Sx

-          Levator resection – ptosis

-          Corrective sx – entropion, ectropion, TED

Consecutive

-          Ptosis props

-          Tape support

-          Temporary occlusion