Ptosis management in orthoptics and ophtalmology

Classification

By Onset

1. Congenital Ptosis

- Present at birth

- Usually due to levator muscle dysgenesis

- Often associated with other ocular conditions

2. Acquired Ptosis

- Aponeurotic (involutional)

- Neurogenic

- Myogenic

- Mechanical

- Traumatic

By Severity

- Mild: 1-2mm drooping

- Moderate: 3-4mm drooping

- Severe: >4mm drooping

Clinical Assessment

Key Measurements

1. Margin Reflex Distance (MRD)

- MRD1: Upper lid to corneal light reflex

- MRD2: Lower lid to corneal light reflex

2. Palpebral Fissure Height

- Normal: 9-11mm

- Measured vertically

3. Levator Function

- Excellent: >12mm

- Good: 8-11mm

- Fair: 5-7mm

- Poor: <4mm

Essential Examinations

1. External Examination

- Lid position

- Lid crease height

- Frontalis muscle action

- Facial symmetry

2. Ocular Examination

- Visual acuity

- Pupillary responses

- Extraocular movements

- Associated conditions

Etiology

Congenital Causes

1. Isolated developmental anomaly

2. Third nerve palsy

3. Marcus Gunn jaw-winking

4. Blepharophimosis syndrome

5. Congenital myasthenia

Acquired Causes

1. Aponeurotic

- Age-related

- Post-surgical

- Contact lens wear

- Trauma

2. Neurogenic

- Third nerve palsy

- Horner's syndrome

- Myasthenia gravis

3. Myogenic

- Chronic progressive external ophthalmoplegia

- Muscular dystrophy

- Myotonic dystrophy

Clinical Features

Common Symptoms

1. Drooping eyelid

2. Visual field limitation

3. Compensatory head posture

4. Eye strain

5. Fatigue

6. Frontalis muscle overaction

Associated Signs

1. Absent/abnormal lid crease

2. Lagophthalmos

3. Exposure keratopathy

4. Amblyopia (in children)

5. Strabismus

Diagnostic Evaluation

Required Tests

1. Visual acuity

2. Visual fields

3. Ocular motility

4. Pupillary examination

5. Ice test (if myasthenia suspected)

Special Investigations

1. Neuroimaging (if indicated)

2. Blood tests

3. Tensilon test

4. EMG studies

5. Genetic testing

Management

Conservative Treatment

1. Observation (mild cases)

2. Ptosis crutches

3. Contact lenses with ptosis prop

4. Medical management of underlying condition

Surgical Options ( ophtalmology )

1. Levator Resection

- Good levator function

- Adult patients

- Moderate to severe ptosis

2. Frontalis Sling

- Poor levator function

- Congenital cases

- Severe ptosis

3. Müller's Muscle Resection

- Mild to moderate ptosis

- Good levator function

- Positive phenylephrine test

Post-operative Care

• Cold compresses

• Regular follow-up

• Lagophthalmos management

Special Considerations

Pediatric Cases

1. Amblyopia risk

2. Timing of surgery

3. Visual development

4. Head posture

5. Regular monitoring

Elderly Patients

1. Underlying conditions

2. Medication effects

3. General health status

4. Recovery expectations

Complications

Surgical Complications

1. Under/overcorrection

2. Asymmetry

3. Exposure keratopathy

4. Infection

5. Scarring

Long-term Issues

1. Recurrence

2. Dry eye

3. Cosmetic concerns

4. Vision problems

5. Psychological impact

Prognosis

Factors Affecting Outcome

1. Etiology

2. Severity

3. Age at onset

4. Treatment timing

5. Surgical technique

Conclusion

Ptosis requires careful evaluation and individualized treatment planning. Success depends on accurate diagnosis, appropriate surgical technique selection, and careful post-operative management. Regular follow-up is essential for optimal outcomes.

Note : This document serves educational purposes exclusively and does not constitute medical advice or treatment guidelines