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Drooping lids in kids!

Congenital Ptosis⁣

⁣AD⁣, Myogenic dysgenesis of the LPS -fibrous & adipose tissue in muscle belly⁣

Impairs ability of muscle to contract and elevate lids⁣

May occlude pupil - amblyopia⁣

Compression of eyeball by ptotic lid⁣ - astigmatism⁣

Severe bilateral congenital ptosis - compensatory head posture- chin up position - to obtain good vision ⁣

Simple congenital ptosis⁣

Due to dystrophy of LPS⁣

Increases in upgaze⁣

Lid lag in downgaze as muscle does not relax⁣


Lid crease absent ⁣

LPS action <4mm⁣

Synkinetic ptosis⁣

Aberrant innervation of LPS muscle by mandibular branch of 5th⁣ nerve ⁣

Marcus-Gunn jaw winking⁣

Brisk upper lid retraction- mastication, jaw thrusting to opp side, chewing,⁣

smiling, jaw protrusion or sucking due to ipsilateral pterygoid muscle contraction⁣

Infants while bottle/breast-fed⁣

Aponeurotic ptosis⁣

Aponeurosis fails to insert on anterior surface of the tarsus/from birth trauma⁣

following forceps delivery⁣

Skin crease may remain normal or high without lid lag on down gaze, good LPS⁣


Blepharophimosis syndrome⁣- AD⁣

Blepharophimosis,telecanthus,epicanthus inversus,ptosis⁣

⁣Ovarian failure,arched palate,cardiac defects⁣

Neurogenic ptosis⁣

Ptosis,miosis,anhidrosis and progressive heterochromia - Horner’s⁣ Syndrome⁣

Rule out:congenital varicella,vascular lesions of internal carotids/subclavian⁣

artery & tumors of neck and mediastinum⁣

Congenital third nerve palsy⁣


Ptosis, inability to elevate, depress or adduct eye, dilated pupil⁣

Pupil - paradoxically small & non-reactive - sign of aberrant regeneration⁣

Others⁣: Birth trauma, Duane syndrome, CFEOM, Kearns Sayre syndrome, Myotonic dystrophy, Myasthenia⁣

Surgical Indications⁣: Stimulus deprivation/induces astigmatism that is amblyogenic⁣, Cosmesis⁣


Frontalis Sling-< 3-4 years of age with poor LPS function⁣

Levator resection & advancement - LPS function >5mm⁣

LPS <3mm - frontalis suspension, frontalis muscle flap, Whitnall's ligament suspension⁣

Whitnall sling (with/without tarsectomy) - cases of relapse after⁣ frontalis suspension and vice versa⁣


Muller’s muscle conjunctival resection

Image from Rajan Eye Care Hospital

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