Ptosis

Ptosis, or lid droop, is a relatively common condition. The majority of cases are congenital. In some cases, ptosis may occur after ocular surgery. All cases of acquired ptosis deserve a careful evaluation because of the potential neurologic implications. Certainly high on the list of possible causes are myasthenia gravis, third nerve palsy, and Horner syndrome. Physical alteration of the lid due to hordeola, chalazia, lid cellulitis, and tumors may present as ptosis.

Differential Diagnosis

• Must differentiate true ptosis from lid retraction, which occurs primarily from chemical stimulation (phenylephrine) or thyroid disease
• Of all cases of ptosis, 60% are believed to be congenital; may be exacerbated with fatigue and age
• Dermatochalasis (drooping tissue) may simulate ptosis
• Lid conditions such as hordeola, chalazia, and lid cellulitis may present as ptosis
• Previous lid or ocular surgery
• Traumatic ptosis
• Marcus Gunn (also called jaw-winking) syndrome
• Myasthenia gravis
• Third nerve palsy from hypertension, diabetes, aneurysm
• Horner syndrome
  –Sympathetic lesion causing partial ptosis, miosis, and anhidrosis
  –Caused by tumors, aneurysms, inflammatory processes, injuries, or chest surgery
• Acquired myogenic ptosis from local or diffuse muscular disease, such as muscular dystrophy, chronic progressive external ophthalmoplegia, or oculopharyngeal dystrophy
• Chromosomal disorders
  –Turner syndrome, trisomy 18, 4p-, 18p
• Fetal drug exposure
  –Alcohol, hydantoin, trimethadione
• Inherited syndromes
  –Noonan, Smith-Lemli-Opitz, Aarskog
• Migraine
• Botulism
• Poisoning
  –Lead, arsenicals, carbon monoxide
• Thiamine deficiency
• Carnitine deficiency
• Vitamin E deficiency
• Tangier disease
• Hydrocephalus

Workup and Diagnosis

• History
  –Evaluate status of known systemic diseases
  –Evaluate for congenital ptosis by checking previous photographs, and/or asking family/friends
  –PMH/PSH: Previous lid or ocular surgery, trauma to the head or orbital region

• Physical exam
  –Visual acuity, visual fields, dilated fundus exam
  –Evaluation for localized lesions of the lid, including hordeola, chalazia, and lid cellulitis
  –With lid droop and no anisocoria, consider myasthenia, neurological causes
  –With lid droop and anisocoria (pupil difference) consider Horner with miosis, third nerve with mydriasis
  –Evidence of third nerve palsy: Fixed, dilated pupil or impaired extraocular muscle movements
  –Evaluate for anomaly associated with jaw movement, e.g., Marcus Gunn syndrome

• Labs
  –CBC/differential for suspected Horner syndrome
• Studies
  –For suspected Horner syndrome, perform CXR, neuroimaging; for third nerve palsy, neuroimaging for aneurysm, tumor, uncal herniation, cavernous sinus lesion, and orbital disease
• Myasthenia may be systemic or ocular and necessitates a Tensilon test for diagnosis

Treatment

• Congenital ptosis may be repaired through oculoplastic surgery
• Dermatochalasis may be corrected through oculoplastic surgery
• Hordeola may be resolved by hot compresses, oral antibiotics, supplemented by topical antibiotics as needed
• Chalazia may be addressed with hot compresses but usually require excision
• Lid cellulitis must be treated aggressively with oral antibiotics
• Appropriate neurosurgical or systemic intervention
• Oculoplastic surgery for recalcitrant cases
• Treatment of any underlying disease

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 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: Pediatric 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 (Differential Diagnosis in Primary Care)
• All Book Extracts: All Online Book Extracts for Droopy eye-lid

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: PTOSIS (Differential Diagnosis in Primary Care)

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