Ptosis (Blepharoptosis)
🔹 Definition
- Ptosis
= upper eyelid drooping จากความผิดปกติของกลไกยก eyelid
- อาจเป็น sign ของ neurologic disease
รุนแรง
- ถ้าบัง visual axis →
functional disability
🔹 Anatomy (high-yield)
- Levator
palpebrae superioris (CN III) →
main elevator
- Müller’s
muscle (sympathetic) →
ยกเพิ่ม ~1–2 mm
- Orbicularis
oculi (CN VII) → ปิดตา
🔹 Key measurements
- MRD1
(margin reflex distance 1) = 4–5 mm (สำคัญสุด) จาก central
light reflex to upper lid margin
- Palpebral
fissure (PF) = 9–12 mm
- Levator
function (LF)
- 12
mm = normal
- ↓ = myogenic / neurogenic /
NMJ
🔹 Clinical approach
🧾 History (key questions)
- congenital
vs acquired
- acute
vs progressive
- fluctuating?
(→ MG)
- diplopia
/ headache (→ neuro)
- trauma
/ surgery / contact lens
- family
history
🔍 Examination
1.
Look
o chin-up
posture, eyebrow elevation
2.
Measure
o MRD1,
PF, lid crease
3.
Levator function
4.
Pupil
o mydriasis
→ CN III
o miosis
→ Horner
5.
EOM
6.
Fatigability test
o sustained
upgaze (> 1 min) / Cogan lid twitch →
MG
🔴 Red flags (ต้องรีบ evaluate)
- ptosis
+ diplopia / ophthalmoplegia
- ptosis
+ anisocoria
- acute
onset
👉 suspect CN III palsy / Horner / intracranial lesion
🔹 Etiology (high-yield
classification)
1. Congenital
- levator
dysgenesis
- unilateral
> bilateral
- ↓ levator function
- risk:
amblyopia / strabismus
2. Aponeurotic (most common in adults)
- levator
aponeurosis dehiscence (เอ็นยึดเปลือกตาหย่อน)
- LF
normal
- high
lid crease
- cause:
- aging
(involutional)
- contact
lens
- post-op
/ trauma
3. Mechanical
- eyelid
mass / edema / tumor
- dermatochalasis
👉 heavy lid → ptosis
4. Neurogenic
🧠 CN III palsy
- ptosis
+ ophthalmoplegia ± dilated pupil
- emergency
→ rule out
aneurysm
🧠 Horner syndrome
- triad:
- mild
ptosis (1–2 mm)
- miosis
- anhidrosis
- anisocoria
↑ in dark
5. Neuromuscular junction
⚡ Myasthenia gravis
- hallmark
= fluctuating + fatigable
- ±
diplopia
- Cogan
lid twitch, ice pack test positive
6. Myogenic
- mitochondrial
myopathy (CPEO)
- myotonic
dystrophy
- OPMD
👉 bilateral progressive + EOM involvement
7. Pseudoptosis
- enophthalmos
- hypotropia
- contralateral
lid retraction
- dermatochalasis
🔹 Diagnosis
- clinical
เป็นหลัก
- imaging
เฉพาะ:
- CN
III palsy
- Horner
syndrome
👉 หา underlying cause
🔹 Management
1. Treat underlying cause
- MG → medical therapy
- Horner
→ treat cause ±
apraclonidine
- botox-induced
→ observation
2. Medical (selected cases)
- Oxymetazoline
eye drops
- ↑ Müller muscle tone
- ↑ MRD1 ~1 mm
- eyelid
crutch (temporary)
3. Surgery (mainstay)
Indications
- visual
axis obstruction
- cosmetic
concern
Type
- good
LF → levator
advancement
- mild
ptosis → Müllerectomy
- poor
LF → frontalis sling
⚠️ Complications
- lagophthalmos
→ exposure keratopathy
- asymmetry
/ under- or overcorrection
🔹 Clinical pearls (ใช้จริงใน ER/clinic)
- ptosis
+ dilated pupil = aneurysm until proven otherwise
- ptosis
fluctuating = think MG
- ptosis
+ miosis = Horner
- LF
normal + high crease = aponeurotic (most common)
- bilateral
progressive + EOM →
myopathy
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