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Strabismus > Ptosis > Flashcards

Ptosis Flashcards

1
Q

What is ptosis

A

Drooping of the upper lid,
may be partial or complete

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2
Q

What conditions cause ptosis

A

Pseudo ptosis
3rd nerve palsy- sup division
Congenital
CFEOM
CPEO
Myastenia gravis

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3
Q

How can ptosis affect diplopia

A

The lid can be an occluder for the diplopia

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4
Q

What does the limbus mark

A

the transition between the cornea and sclera

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5
Q

When the eye is open in primary position….

A

upper lid margin just covers the upper cornea
2mm below upper limbus
lower lid margin lies just below the cornea
Some people – slightly above

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6
Q

Can palpebral fissure shape vary ethically

A

Yes

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7
Q

What is the mechanism when the eyelids close

A

The orbicular contracts

The levator palpebrae superioris relaxes

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8
Q

What is the mechanism when the eyelids open

A

The levator palpebrae superioris contracts

The orbicularis relaxes

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9
Q

What are the elevators of the upper eyelid

A

Levator palpebrae superiosis (LPS)
Mullers muscle

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10
Q

What supplies the LPS

A

Superior division on 3rd nerve

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11
Q

What supplies Mullers muscle

A

Sympathetic fibres

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12
Q

What connects the LPS and lid

A

Aponeurosis

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13
Q

What to document in ptosis patient

A

Unilateral / bilateral?
Facial asymmetry?
Head posture?
?Forehead creases

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14
Q

What type of AHP do ptosis children have and why

A

Chin elevation improves VA

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15
Q

What is the orthoptic investigation for ptosis

A

VA
CT
BSV
OM
Pupils

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16
Q

Can adults have congenital ptosis

A

YES

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17
Q

What are more specific qs about ptosis

A

Onset
Recent tx e.g. BT
Change
Signs
Symptoms
Variability
FH
GH

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18
Q

Can cosmetic botox cause ptosis

A

Yes it can leak into other muscles

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19
Q

What is the frontalis

A

The only muscle that raises the eyebrows

Children can use frontalis to elevate the lid

Frontalis can be used surgically to help with ptosis

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20
Q

How to record ptosis

A

Size
Which eye
How many 3rd of lid covered

21
Q

Examples of ptosis recording

A
  • Mrdk bilateral ptosis
    R covering ¾
    L slight ptosis
  • sl L ptosis using frontalis
22
Q

What can the frontal compensate for

A

ptosis so comment if it is with to without frontalis muscle

23
Q

What are the normal upper lid margin ranges

A

2mm below upper limbus

24
Q

What are the normal lower lid margin ranges

A

1mm above lower limbus

25
Q

What is marginal reflex distance

A

the distance between the CR & upper lid margin

26
Q

Leavator function ranges

A

Normal: > 15mm
Good: > 12mm
Fair: 5-11mm
Poor: < 4mm

27
Q

If there is lid lag on down gaze the levator is….

A

unable to relax properly when looking down so lid elevates (congenital ptosis)

28
Q

What is a dystrophic levator muscle

A

lid lag on down gaze

29
Q

What happens if levator not dystrophic

A

Ptosis in all positions

30
Q

What is simple congenital ptosis

A

Developmental dystrophy of levator muscle. It’s occasionally associated with SR weakness

31
Q

What is the skin crease formed by

A

insertion of levator aponeurosis

observe for pp and downsize

measure on down gaze

normal downgaze measurement
M- 8MM
F- 10MM

32
Q

Use of AHP and what is a good sign for

A

trying to maintain BSV
maximising VA & VF (seeing under the ptosis)
bilateral ptosis

good sign for VA

33
Q

What to observe in ocular movement testing

A

epicanthus
facial features
facial asymmetry
lid closure
Bell’s phenomenon
SR function
jaw winking
variability
Cogan’s lid twitch
aberrant movements
pupils
lid on downgaze

34
Q

Why is fundus check important

A

There may be dual pathology and syndromes such as Kaern sayer which is a mitochondrial myopathy

35
Q

What type of ptosis does Kaerns Sayer cause

A

Bilateral

36
Q

Why does astigmatism cause ptosis

A

Due to pressure on cornea

37
Q

What conditions can also have ptosis

MMAN

A

Myogenic

Neurogenic

Mechanical

Aponeurotic

38
Q

What myogenic disorders cause ptosis

A

Due to levator muscle defect

MG, myotonic dystrophy, CPEO, congenital ptosis (SR weakness associated), Kaerns sayer, blepharophimosis syndrome

39
Q

What is blepharophimosis syndrome

A

Ptosis, telecanthus, epicanthus inversus
AD inheritance
Strabismus & refractive error common
ET>XT>HT
May have nystagmus
Amblyopia common
(small eyes)

Telecanthus: eyes appear more widely spaced.
Epicanthus inversus: skin fold arising from lower inner eyelid.

39
Q

What neurogenic disorders cause ptosis

A

Sup devision 3rd NP
Marcus Gunn
Horners (no swear on one side of face, miosis and ptosis)

40
Q

What mechanical problems can cause ptosis

A

Something increasing weight of upper lid e.g. fat
Scar tissue e.g. post op or chemical burn
Trauma e.g. birth with forceps

41
Q

What is aponeurotic ptosis

A

weakness in leaver aponeurosis which restricts transmission of force from normal levator muscle to upper lid

41
Q

Common features of aponeurotic ptosis

A

good levator function
high upper lid crease
no lid lag on down gaze
bilateral ptosis
worse at end of day (not to be confused with MG)

42
Q

Differential diagnosis

A

Pseudo ptosis (true can co exist)
Duanes

43
Q

What is the management of ptosis

A

Amblyopia treatment
Treat the cause- steroids, propranolol oral
MG treatment- Prednisone, immunosuppressant

44
Q

What are some conservative management options

A

Ptosis props
(adaptation to glasses
metal bar / loop to lift upper lid)

Paeds (lift lid with finger or thumb)

45
Q

What are the surgical options and aims

FCLLLBW

A

AIM- improve position of upper lid margin

Fasenella Servat
Conjunctival-Muller’s muscle resection
Levator aponeurotic repair
Levator resection
Levatorpexy
Brow suspension (severe cong)
Whitnall’s ligament sling

46
Q

How to assess surgical success

A

PP and downgaze

May have lid lag on downgaze so managing patient expectations is important

47
Q

SUMMARY

A

Revise eyelid anatomy

Measure & document ptosis as accurately as possible
levator function

Differentially diagnose true ptosis & pseudo ptosis

Amblyopia treatment
challenging
can be successful

Strabismus (46 decks)

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