Ptosis Types & Clinical Features: Made By:-Amritansh Pandey

PTOSIS
TYPES & CLINICAL

FEATURES
Made By:- Amritansh Pandey

DEFINITION & TYPES
 Ptosis refers to abnormal drooping of upper
eyelid is called ptosis.
 It is of 2 types
1. Congenital Ptosis
2. Acquired Ptosis
CONGENITAL PTOSIS
 Etiology-It is associated with congenital
weakness of the Levator palpebrae
superioris(LPS).
 Characteristic Features-
1. Drooping of one or both upper lids more

often since birth of variable severity.
2. Lid crease is either diminished or absent.
3. Lid lag on downgaze (ptotic lid is higher

than normal).
4. LPS function may be poor, fair or good
depending upon degree of weakness.
 Associated features-
1. Simple congenital ptosis (not associated
with anomaly).
2. Congenital ptosis with associated weakness
of superior rectus muscle.
3. Blepharophimosis syndrome which
comprises congenital ptosis,
blepharophimosis, telecanthus and
epicanthus inversus.
4. Congenital synkinetic ptosis.
ACQUIRED PTOSIS
 Neurogenic ptosis- Caused by innervational defects such
as
1. Third nerve palsy
2. Horner’s syndrome
3. Ophthalmic migraine
4. Multiple sclerosis
 Horner’s syndrome, occuring due to oculo-sympathetic

paresis is characterised by a classical triad of:-
1. Mild ptosis
2. Miosis
3. Reduced ipsilateral sweating
 Other features include mild enophthalmos, heterochromia.

 Acquired myogenic ptosis:- Occurs due to
acquired disorder of LPS muscle or of the
myoneural junction. It maybe seen with
myasthenia gravis, dystrophica myotonica,
ocular myopathy, oculopharyngeal muscular
dystrophy and following trauma to the LPS,
muscle thyrotoxicosis and Lambert-Eaton
myasthenia syndrome.
 Aponeurotic ptosis:- It develops due to
defects of levator aponeurosis in presence of
normal functioning muscle. It includes:
1. Involutional (senile) ptosis.
2. Postoperative ptosis (which is rarely

observed after cataract and retinal
detachment surgery).
3. Ptosis due to aponeurotic weakness
associated with blepharochalasis.
4. Traumatic dehiscence or disinsertion of the
aponeurosis.
 Mechanical ptosis:- It may result due to
excessive weight on the upper lid as seen in
patients with lid tumors, multiple chalazia
and lid oedema.
 It may also occur due to scarring as seen in
patients with ocular pemphigoid and
trachoma.
CLINICAL EVALUATION
 History:- including age of onset, family
history, history of trauma, eye surgery and
variability in degree of ptosis.
 Examination
1. Exclude pseudoptosis (simulated ptosis)

on inspection. Its common causes are:
 Ipsilateral conditions such a
microphthalmos, phthisis bulbi,
enophthalmos, prosthesis, brow ptosis,
dermatochalasis and hypotropia.
 Contralateral conditions include: eyelid
retraction, high myopia and proptosis.
2. Observe the following points in each case:
 Whether ptosis is unilateral or bilateral. Causes of
bilateral ptosis include congenital ptosis,
myasthenia gravis, myotonis dystrophy, Kearne-
Sayre syndrome, Lambert-Eaton myasthenic
syndrome and chronic progressive external
ophthalmoplegia.
 Function of orbicularis oculi muscle.
 Eyelid crease is present or absent.
 Jaw-winking phenomenon is present or not.
 Associated weakness of any extraocular muscle.
 Bell’s phenomenon(up and controlling of the

eyeball during forceful closure).
3. Measurement of amount(degree) of
ptosis.
 In unilateral cases, difference between the
vertical height of the palpebral fissures of two
sides indicates the degree of ptosis.
 In bilateral cases it can be determined by
measuring the amount of cornea covered by
upper lid and then subtracting 2mm.
 Ptosis is graded depending on its amount as:
1. Mild ptosis: 2mm
2. Moderate ptosis: 3mm
3. Severe ptosis: 4mm

4. Margin reflex distance(MRD) refers to the
distance between the upper lid margins and
corneal light reflex.
 Normal value of MRD is 4-5mm.
5. Assessment of levator function. It is

determined by the lid excursion caused by LPS
muscle(Burke’s method).Levator function is
graded as follows
Normal: 15mm
Good: 8mm or more
Fair: 5-7mm
Poor: 4mm or less
6. Special investigations
1. Tensilon test is performed when myastgenia is
suspected. There occurs improvement of ptosis
with intravenous injection of edrophonium
(tensilon) in myasthenia.
2. Phenylephrine test is carried out in patients
suspected of Horner’s syndrome.
Neurological investigations maybe required to find out
the cause in patient with neurogenic ptosis.
7. Photographic record of the patient should be

maintained for comparison. Photographs should be
taken in primary position as well as in up and down
gazes.
THANK YOU

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PTOSIS

TYPES & CLINICAL

Made By:- Amritansh Pandey

1. Drooping of one or both upper lids more

3. Lid lag on downgaze (ptotic lid is higher

 Horner’s syndrome, occuring due to oculo-sympathetic

 Other features include mild enophthalmos, heterochromia.

2. Postoperative ptosis (which is rarely

1. Exclude pseudoptosis (simulated ptosis)

 Eyelid crease is present or absent.

 Jaw-winking phenomenon is present or not.

 Associated weakness of any extraocular muscle.

 Bell’s phenomenon(up and controlling of the

1. Mild ptosis: 2mm

2. Moderate ptosis: 3mm

3. Severe ptosis: 4mm

5. Assessment of levator function. It is

7. Photographic record of the patient should be

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