PTOSIS

A drooping eyelid may result from direct involvement of the levator palpebrae superioris muscle (end organ) or from involvement of the sympathetic or oculomotor nerve pathways from the muscle to the central nervous system. Consequently, visualizing neuroanatomy is the key to a differential diagnosis.

1. End organ (levator palpebrae superioris muscle). The end organ can be involved in congenital ptosis (defective development of the muscle), injury to the tendon of the muscle, neoplasms of the eye or orbit, or dermatomyositis.
2. Sympathetic pathway. If the sympathetic pathways are involved there is almost invariably an associated miosis and enophthalmos (Horner syndrome). The lesion may be along the intracranial pathways of the postganglionic fibers around the carotid artery in internal carotid aneurysms, thrombosis, and migraine. Orbital cellulitis or tumors may rarely affect the sympathetic nerve pathways here. The lesion may be in the stellate ganglion and its connections in cervical rib, scalenus anticus syndrome, Pancoast tumors, cervical Hodgkin lymphoma, and brachial plexus injuries. The lesion may be in the spinal cord or nerve roots in spinal cord tumors, syringomyelia, syphilis, thoracic spondylosis, metastatic carcinoma, myeloma, or tuberculosis of the spinal column. Finally, the lesion may be in the brainstem in gliomas, posterior inferior cerebellar artery occlusions, syringobulbia, and encephalitis.
3. Oculomotor nerve pathways. When the ptosis is due to involvement in this pathway, there are usually other extraocular muscle palsies as well. The levator muscle may be affected by myotonic dystrophy. The myoneural junction may be affected by myasthenia gravis. The oculomotor nerve may be involved by orbital tumors or cellulitis by compression from herniation of the uncus in cerebral tumors or subdural hematomas, by cavernous sinus thrombosis or carotid aneurysms, and occasionally by syphilitic or tuberculous meningitis or pituitary and suprasellar tumors. Diabetic neuropathy may cause ptosis due to oculomotor nerve involvement. In the brainstem, the nuclei or supranuclear connections of the oculomotor nerve may be involved by syphilis (e.g., general paresis), gliomas, pinealomas, basilar artery occlusions, encephalitis, botulism, and progressive muscular atrophy.

Approach to the Diagnosis

As always, the diagnosis is usually established by the presence or absence of other neurologic signs and symptoms. Bilateral partial ptosis suggests myotonic dystrophy, a congenital origin, or progressive muscular dystrophy. Unilateral ptosis without miosis or extraocular muscle palsy suggests injury to the levator palpebrae superioris muscle or myasthenia gravis. A Tensilon test should always be considered. When all the components of Horner syndrome are present, x-rays of the skull, cervical and thoracic spine, and chest should be done. A spinal tap and arteriography should be considered. If oculomotor involvement is certain, a glucose tolerance test, skull x-rays, serologic tests for syphilis, spinal tap (if no contraindications), CT scans, and, possibly, arteriography are indicated. The need for other tests depends on the presence of other neurologic signs. An ophthalmologist and neurologist should probably be consulted in all cases of unilateral ptosis.

Other Useful Tests

1. CBC (orbital cellulitis)
2. ANA analysis (collagen disease)
3. Acetylcholine receptor antibody titer (myasthenia gravis)
4. MRI of the brain (brain tumor or other space-occupying lesion)
5. Cerebral angiogram (cerebral aneurysm)
6. Response to intravenous thiamine (Wernicke encephalopathy)
7. 24-hour urine creatinine and creatine (muscular dystrophy)
8. CT scan of mediastinum (mediastinal tumor, aneurysm)
9. Chest x-ray (malignancy)
10. Lymph node biopsy (lymphoma)

Pictures

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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