Ptosis

Ptosis is a drooping of the upper eyelid, which may cause decreased vision by direct visual obstruction or by inducing corneal astigmatism. Ptosis may be a harbinger of a more serious medical condition, including myasthenia gravis, CPEO (due to heart block), third nerve palsy (aneurysm), and Horner's syndrome (Pancoast or other tumors).

Differential Diagnosis

• Differentiate from lid edema (e.g., post-trauma), pseudoptosis/dermatochalasis (excess skin of upper lids), enophthalmos (narrowed palpebral fissure), hypotropia, contralateral eyelid retraction causing asymmetry, small eye (phthisis bulbi, microphthalmia, anophthalmia)
• 
  Acquired
• Aponeurotic or senile ptosis
  –Most common type of ptosis
  –Caused by disinsertion or dehiscence of the levator aponeurosis
  –Normal levator function, high lid crease
  –May be exacerbated by any ocular surgery
• Mechanical
  –Caused by mass effect of tumor or edema or by tethering by scar (cicatricial)
• Myogenic
  –Poor levator or Müller's muscle function
  –Myasthenia gravis (variable ptosis)
  –CPEO
  –Myotonic dystrophy
• Neurogenic
  –Third nerve palsy [associated supraduction deficit; may also have adduction or infraduction deficit, eye may be down and out; mydriasis]
  –Horner's syndrome [associated with miosis (1–2 mm pupil), “reverse ptosis” (lower lid higher), and often anhidrosis]; due to many etiologies, including Pancoast tumor and neuroblastoma
  Congenital
• Simple congenital (myopathic) ptosis
  –Poor levator function, lid lag in downgaze
  –Subset of blepharophimosis syndrome (bilateral ptosis, horizontal shortened palpebral fissures, and telecanthus with dominant inheritance)
• Congenital Horner's syndrome (associated with vertebral anomalies)
• Marcus Gunn jaw-winking syndrome (unilateral ptosis at rest; when chewing or opening mouth the ptotic lid raises up)
• Mitochondrial myopathies

Workup and Diagnosis

• History should include age of onset, previous surgeries or trauma, variability of ptosis, diplopia, associated symptoms (e.g., dysphagia), and attempt to observe old pictures of patient, if possible

• Exam should include a complete ophthalmologic examination and focused neurologic, head and neck, and chest examinations
  –In children, rule out amblyopia from induced astigmatism or occlusion
  –Note levator function, palpebral fissure width, pupils, extraocular motility (especially supraduction), corneal sensation, corneal surface, Bell's phenomenon (eyes roll up with lid closure), and Shirmer's strips (to quantify basal secretion of tears)
• Tensilon test or ice test to rule out myasthenia gravis
• Topical cocaine and hydroxyamphetamine drops to rule out Horner's syndrome
• Visual fields with and without lids taped up to document significant superior visual field defect
• Photodocumentation; compare with old photos
• Consider CT/MRI or ophthalmology consult for possible tumors or scar
• Chest X-ray if suspect Horner's syndrome to rule out pulmonary lesion
• MRA if painful ptosis to rule out carotid dissection

Treatment

• Treat underlying medical condition when possible
• Eyelid crutches attached to glasses may be used as temporizing measures, but may limit blinking and result in dry eyes
• Eyelid surgery may be necessary
• In children under age 10, if amblyopia in induced, surgical correction should be performed as soon as possible

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

Other Book Chapters Related to Droopy eye-lid

Read excerpts from these other book chapters related to Droopy eye-lid:

Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Droopy eye-lid

• Back to symptom: Droopy eye-lid: Introduction (review 419 causes)
• Next Book Extract About Droopy eye-lid: Ptosis (In A Page: Pediatric Signs and Symptoms)
• All Book Extracts: All Online Book Extracts for Droopy eye-lid

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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