evaluation of ptosis

EVALUATION OF PTOSISBY DR NIKITA JAISWAL

MS RESIDENT

IMS AND SUM HOSPITAL

BLEPHAROPTOSIS

OR

PTOSIS:ABNORMALLY LOW POSITION OF UL IN PRIMARY GAZE

IN NORMAL GAZE IT COVERS 1/6TH OF THE CORNEA, I.E 2 MM .

IN PTOSIS IT COVERS MORE THAN THAT.

PTOSIS {DERIVED FROM: GREEK LANG.}

MEANS : TO FALL

Mr bell clicked it in 1952

BEFORE ANY JUDGEMENT WE NEED TO DIFFERENTIATE BETWEEN :-

PSEUDOPTOSIS[SIMULATED PTOSIS}

TRUEPTOSIS

PSEUDOPTOSIS :IT IS TO BE RULED OUT ON INSPECTION IPSILATERAL CONDN: MICROPHTHALMOS

PTHISIS BULBIENOPHTHALMOSPROSTHESISDERMATOCHALASIS

CONTRALATERAL CONDN: EYELID RETRACTIONHIGH MYOPIAPROPTOSIS

ptosis

acquired

NEUROGENIC

MYOGENIC

APONEUROTIC

MECHANICAL

congenital

PSEUDOPTOSIS

Pthisis bulbi Enophthalmos

PRESENTING COMPLAINTS OF THE PATIENTDrooping of the eyelids

since a definite period

Associated decreased vision unaware of the

eyelids

GRADING: MILD PTOSIS: 2MMMODERATE PTOSIS: 3 MMSEVERE PTOSIS : 4 MM

EVALUATION

CLINICAL EVALUATION FOLLOWS:

HISTORY:THE RULE OF “ODP” SHOULD BE KEPT IN MIND

THROUGH HISTORY SHOULD BE EXTRACTED FROM THE PATIENT THE PREVIOUS PHOTOGRAPH CAN HELP DISTINGUISH THE AGE OF PTOSIS ASTHE PATIENT MAY BE GIVING IRRELEVANT HISTORY.

MARGIN-REFLEX DISTANCE: DISTANCE BETWEEN THE UPPER LID MARGIN AND THE CORNEAL REFLECTION OF A PEN TORCH HELD BY US AT WHICH THE PATIENT IS DIRECTLY LOOKING.

NORMAL IS 4-4.5 MM

PALPEBERAL FISSURE HEIGHT: DIST BETWEEN THE UL AND LL MARGINS

THE UL MARGIN 2MM BELOW THE UPPER LIMBUS AND THE LL MARGIN 1MM ABOVE THE LOWER LIMBUS

IN MALES: 7-10 MM

IN FEMALES: 8-12 MM CAN BE CLASSIFIED AS MILD

MODERATESEVERE

LEVATOR FUNCTION:PLACE A THUMB FIRMLY OVER PATIENTS BROW TO NEGATE

THE ACTION OF FRONTALIS MUSCLE WITH THE EYES IN DOWNGAZE THEN THE PATIENT IS ASKED TO LOOK UP AS FAR AS POSSIBLE THEN THE EXCURSION IS MEASURED BY A RULER.

UPPER LID CREASE: IT IS VERTICAL DISTANCE BETWEEN THE LID MARGIN AND THE LID

CREASE IN DOWNGAZE………

FEMALES:10 MMMALES: 8 MM

ASSOCIATED SIGNS:FATIGABILITY: ASK THE PAT. TO LOOK UP WITHOUT BLINKING FOR 30 SECONDS IF

THE PATIENTS FAILS TO MAINTAIN THE UPWARD GAZE IS SUGGESTIVE OF M.G COGAN TWITCH SIGN: OVERSHOOT OF THE UL ON SACCADE FROM DOWNGAZE TO THE PRIMARY POSITION.

JAW WINKING PHENOMENON:CAN BE SEEN IF THE PATIENT IS PTOTIC

AND WE ASK THE PATIENT TO CHEW OR OPEN HIS/HER MOUTH.

BELLS PHENOMENON: IT IS TESTED BY MANUALLY HOLDING THE LIDS

OPEN,ASKING THE PATIENT TO TRY TO SHUT HIS EYES AND OBSERVING THE UPWARD AND OUTWARD ROTATION OF THE GLOBE

OTHER BATTERY OF TESTS

THIS TEST IS AN EASY OPD BASE PROCEDURE

ASK THE PATIENT TO SIT COMFORTABLY ASK HIM/HER TO CLOSE THEIR EYESHOLD AN ICE PACK OVER THE CLOSED EYESWAIT FOR 5 MINUTESOBSERVE AFTER 5 MINUTES NOTE ANY IMPROVEMENTS

EDROPHONIUM(TENSILON)TEST:EDROPHONIUM CHLORIDE INHIBITS ACETYLCHOLINESTERASEIT RESULTS IN THE PROLONGED PRESENCE OF ACT A THE NMJTHIS RESULTS IN ENHANCED MUSCLE STRENGTH POSITIVE: ELEVATION OF EYELIDS IN 2-5MINS POST ADMINISTRATION OF TENSILONNEGATIVE: NO IMPROVEMENT EVEN 3 MINUTESDRAWBACK: THIS HAS A RELATIVELY LOW SENSITIVITY APPROX. 60% FOR MGS/E: DUE TO OVERACTIVATION OF THE PARASYMPATHETIC SYSTEM & CAUSE UNWANTED S/E FAINTING,DIZZINESS,INVOLUNTARY DEFECATION, SEVERE BRADYCARDIA,APNEA, AND THE MOST DREADED ONE CARDIAC ARREST.SAVIOR: ATROPINE AT HAND

OPTIONS ARE EVERYWHERE

EYELIDS CRUTCHES A PROTOTYPE EXTERNAL MAGNETS