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
normally
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
function
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
Partial/complete
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
Surgeries
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
Fasanella-Servat
Muller’s muscle conjunctival resection
Image from Rajan Eye Care Hospital
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