Adult Ptosis

Adult PtosisRandy M Rosenberg md faan facpAssistant professor of neurologyLewis Katz School of Medicine at Temple University

Functional AnatomyLevator palpebrae superioris Primary muscle for lid elevationArises from the back of the orbit and extends forwards over the cone of eye musclesInserts into the eyelid and the tarsal plate, a fibrous semicircular structure which gives the upper eyelid its shapeInnervated by the superior division of the oculomotor nerveMullers muscles (superior tarsal muscle)Involuntary muscles comprising sympathetically innervated smooth muscleHas the capacity to tighten the attachment and raise the lid a few millimeters (1-3mm of lid retraction)

Functional AnatomyFrontalis muscle and Obicularis oculiFrontalis elevates the eyelid indirectlyNote Georges frontal wrinklesObicularis oculi depresses eyelidBoth are innervated by CN VII

Normal Lids

Normal eyelid excursion is 13 mmThe right-sided image shows: a normal eyelid crease (A), upper marginal reflex distance (B)Margin to reflex distance is normally 4-5 mmpalpebral fissure (C)Vertical fissure height is normally 9-10 mm

Left Sided Ptosis

Lid crease is absent on the leftThe crease is up in the sulcus Superior sulcus deformity is present on the left and right, and the patient is elevating her brows. The right upper lid should be checked for an underlying or masked ptosis. If the right lid is ptotic, lifting the left lid causes the right lid to droop.

Simple Bedside Evaluations of Ptosis

Law of Reciprocal Innervation

CN III PalsyDense Ptosis due to paresis of LPSPupillary sparingPupilloconstrictor fibers of externally located and vunlnerable to compressionDeep disease of CN III such as ischemia (e.g. diabetes microangiopathy, granulomatous arteritis) often spares pupil

Horners SyndromeClassic triad:Unilateral ptosis Ipsilateral miosis (mild)Anhidrosis Sudomotor fibers peal off at bifurcation of the carotidAnisocoric is worse in the darkOculosympathetic paresis is dysfunction is one of a three order neuron pathway

Cranial Sympathetics: A Three Neuronal Pathway

Pharmacologic Testing In Horners Syndrome

Apraclonidine Eyedrop Testing in Horners Syndrome

Will quickly determine if a Horners is present but does not distinguish between pre- and post- ganglionic etiology

Paradigm for Acute Horners

Congenital Ptosis

Most cases are due to localized myogenic dysgenesis.The levator muscle and aponeurosis tissues appear to be infiltrated or replaced by fat and fibrous tissue. Frequently the superior rectus will be involved70% involve only one eyeMost cases are noted at birth but may manifest by the 1st year of lifeNote the presence of a lid crease.

Note the upward chin tilt

Elements in the Examination of Congenital Ptosis

Marcus Gunn Jaw Winking Phenomenon

Neurogenic ptosisUsually from congenital ptosisInvolves motor component of CN V and superior division of CN III?Aberrant reinnervationLid elevates with jaw movement

Ptosis in Myasthenia Gravis

Ptosis with sustained up-gazeLid twitch (Cogan's lid twitch sign) With down-gaze to up-gazeLid elevates excessively & then droops againUnilateral or Bilateral Worse side may vary from day to day Worse with sustained up gaze Improved with cold

Ocular Myasthenia

Myogenic ptosisCauses of myogenic ptosisMyastheniaChronic progressive external ophthalmoplegiaOculopharyngeal dystrophyOther dystrophies including myotonicIce test2 minutes and >2 mm