Ptosis

Abnormal drooping of upper eyelid.

---

Etiology

Congenital ptosis

Congenital weakness (maldevelopment) of levator palpebrae superioris (LPS)

• Syndromic associations:

1. Simple congenital ptosis
2. Congenital ptosis with associated weakness of superior rectus muscle
3. Blepharophimosis-ptosis-epicanthus inversus syndrome (BPES)
4. Congenital synkinetic ptosis (Marcus Gunn jaw-winking ptosis)
   • Retraction of ptotic lid with jaw movements

Neurogenic ptosis:

1. Horner’s syndrome (CIII palsy)
2. Ophthalmoplegic migraine
3. Multiple sclerosis (MS)

Acquired myogenic ptosis:

Disorders of LPS or myoneural junction

Aponeurotic ptosis:

• Involutional (senile) ptosis
• Postoperative ptosis
• Ptosis associated blepharochalasis
• Traumatic dehiscence

Mechanical ptosis:

• Cicatricial ptosis

---

Diagnosis

Margin-reflex distance

Distance between upper lid margin and corneal reflection on pen torch held by examiner on which the patient fixates

Palpebral fissure height:

Distance between upper and lower lid margins

• Mild: ≤ 2 mm
• Moderate: ≤ 3mm
• Severe: ≥ 4mm

Levator function (upper lid excursion):

Measured by placing thumb firmly against patient’s brow (to negate action of frantalis muscle) with the eyes in downgaze and the patient then looks up as far as possible.

• Normal: ≥ 15mm
• Good: 12-14mm
• Fair: 5-11mm
• Poor: ≤4mm

---

Management

Congenital ptosis:

1. Fasanella-Sevat operation (tarso-conjunctivo-mullerectomy)
2. Levator resection:
   1. Blaskowick’s operation
   2. Everbusch’s operation
3. Frontalis sling operation (brow suspension)

Acquired ptosis:

• Treat underlying cause
• Conservative treatment
• Surgical treatment