PTOSIS

Ask the Following Questions:

1. Are there abnormalities on the eye examination? Pseudoptosis occurs when there is inflammation of the eyelid, cornea, or other ocular structures. Periorbital edema, conjunctivitis, and trachoma are among the many disorders to consider.
2. Is it intermittent? Intermittent ptosis would suggest myasthenia gravis, ophthalmoplegic migraine, and transient ischemic attacks.
3. Is it partial? The presence of partial ptosis should suggest Horner's syndrome, especially if there is a constricted pupil. However, myotonic dystrophy, myasthenia gravis, and progressive muscular atrophy are just three of the disorders that may present with partial ptosis.
4. Is there a dilated pupil? The presence of a dilated pupil, especially with a unilateral ptosis, suggests a ruptured cerebral aneurysm. However, if the dilated pupil is associated with many other neurologic signs, then there are many other conditions to consider.
5. Is there a constricted pupil? The presence of a constricted pupil with unilateral complete ptosis would suggest diabetic neuropathy. However, if there is bilateral complete ptosis, chronic progressive external ophthalmoplegia and myasthenia gravis should be considered.
6. Are there other cranial nerves involved? The presence of other cranial nerve signs should suggest cavernous sinus thrombosis, cerebral aneurysm, tuberculous meningitis, syphilitic meningitis, Wernicke's encephalopathy, diphtheria, and subdural hematoma.
7. Are there hyperactive reflexes? The presence of hyperactive reflexes would suggest syringomyelia, platybasia, brain stem tumors, vertebral basilar occlusion or insufficiency, multiple sclerosis, epidemic encephalitis, and general paresis.
8. Are there hypoactive reflexes? The presence of hypoactive reflexes would suggest myotonic dystrophy, tabes dorsalis, and progressive muscular atrophy.

DIAGNOSTIC WORKUP

If there are local conditions responsible for the ptosis, then a smear and culture of the exudate and slit lamp examination or tonometry can be done, or the patient should be referred to an ophthalmologist. If a neurologic disease is suspected, a neurologist should be consulted, especially if the onset is acute.

Routine diagnostic tests include a CBC, sedimentation rate, urinalysis, chemistry panel, glucose tolerance test, ANA, VDRL test, and x-rays of the skull and sinuses. A CT scan or MRI of the brain must be done in most cases. If myasthenia gravis is suspected, a Tensilon test and acetylcholine receptor antibody titer can be done.

If encephalitis, meningitis, central nervous system lues, or multiple sclerosis are suspected, a spinal tap may be useful. Intravenous thiamine is administered in Wernicke's encephalopathy. If Horner's syndrome is suspected, the workup may be found on page 227 . If muscular dystrophy is suspected, a 24-hr urine collection for creatinine and creatine and a muscle biopsy may be done. Cerebral angiography will be necessary to diagnose most cerebral aneurysms and cerebral vascular disease, including transient ischemic attacks.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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