Ptosis

Ptosis is the excessive drooping of one or both upper eyelids. This sign can be constant, progressive, or intermittent, and unilateral or bilateral. When it’s unilateral, it’s easy to detect by comparing the eyelids’ relative positions. When it’s bilateral or mild, it’s difficult to detect—the eyelids may be abnormally low, covering the upper part of the iris or even part of the pupil instead of overlapping the iris slightly. Other clues include a furrowed forehead or a tipped-back head—both of these help the patient see under his drooping lids. With severe ptosis, the patient may not be able to raise his eyelids voluntarily. Because ptosis can resemble enophthalmos, exophthalmometry may be required. (See Differentiating enophthalmos from ptosis, page 301.)

Ptosis can be classified as congenital or acquired. Classification is important for proper treatment. Congenital ptosis results from levator muscle underdevelopment or disorders of the third cranial (oculomotor) nerve. Acquired ptosis may result from trauma to or inflammation of these muscles and nerves, or from certain drugs, a systemic disease, an intracranial lesion, or a life-threatening aneurysm. However, the most common cause is advanced age, which reduces muscle elasticity and produces senile ptosis.

History and physical examination

Ask the patient when he first noticed his drooping eyelid and whether it has worsened or improved. Find out if he has recently suffered a traumatic eye injury. (If he has, avoid manipulating the eye to prevent further damage.) Ask about eye pain or headache, and determine its location and severity. Has the patient experienced any vision changes? If so, have him describe them. Obtain a drug history, noting especially use of a chemotherapeutic drug.

Assess the degree of ptosis, and check for eyelid edema, exophthalmos, deviation, and conjunctival injection. Evaluate extraocular muscle function by testing the six cardinal fields of gaze. Carefully examine the pupils’size, color, shape, and reaction to light, and test visual acuity.

Keep in mind that ptosis occasionally indicates a life-threatening condition. For example, sudden unilateral ptosis can herald a cerebral aneurysm.

Medical causes

Alcoholism

Long-term alcohol abuse can cause ptosis and such complications as severe weight loss, jaundice, ascites, and mental disturbances.

Botulism

Acute cranial nerve dysfunction causes hallmark signs of ptosis, dysarthria, dysphagia, and diplopia. Other findings include dry mouth, sore throat, weakness, vomiting, diarrhea, hyporeflexia, and dyspnea.

Cerebral aneurysm

An aneurysm that compresses the oculomotor nerve can cause sudden ptosis, along with diplopia, a dilated pupil, and inability to rotate the eye. These may be the first signs of this life-threatening disorder. A ruptured aneurysm typically produces sudden severe headache, nausea, vomiting, and decreased level of consciousness (LOC). Other findings include nuchal rigidity, back and leg pain, fever, restlessness, irritability, occasional seizures, blurred vision, hemiparesis, sensory deficits, dysphagia, and visual defects.

Dacryoadenitis

Ptosis may accompany unilateral exophthalmos, limited extraocular movements, eyelid edema and erythema, conjunctival injection, eye pain, and diplopia.

Hemangioma

This orbital tumor can produce ptosis, exophthalmos, limited extraocular movement, and blurred vision.

Horner’s syndrome

This disorder causes moderate unilateral ptosis that almost disappears when the patient opens his eyes widely. Common accompanying findings include unilateral miosis and ipsilateral anhidrosis of the face and neck, which may spread to the entire body. Other signs and symptoms include transient conjunctival injection, vascular headache on the affected side, and vertigo.

Lacrimal gland tumor

This disorder commonly produces mild to severe ptosis, depending on the tumor’s size and location. It may also cause brow elevation, exophthalmos, eye deviation and, possibly, eye pain.

Levator muscle maldevelopment

Ptosis from maldevelopment of the levator muscle of the upper eyelid—formerly classified as true congenital ptosis—is the result of an isolated dystrophy of the levator muscle affecting its contraction and relaxation. Lid lag on downgaze is an important clue to diagnosis.

Myasthenia gravis

Commonly the first sign of this disorder, gradual bilateral ptosis may be mild to severe and is accompanied by weak eye closure and diplopia. Other characteristics include muscle weakness and fatigue, which eventually may lead to paralysis. Depending on the muscles affected, other findings may include masklike facies, difficulty chewing or swallowing, dyspnea, cyanosis, and others.

Myotonic dystrophy

This disorder may cause mild to severe bilateral ptosis. Distinctive cataracts with iridescent dots in the cortex, miosis, diplopia, decreased tearing, and muscular and testicular atrophy may also occur.

Ocular muscle dystrophy

With this disorder, bilateral ptosis progresses slowly to complete eyelid closure. Related signs and symptoms include progressive external ophthalmoplegia and muscle weakness and atrophy of the upper face, neck, trunk, and limbs.

Ocular trauma

Trauma to the nerve or muscles that control the eyelids can cause mild to severe ptosis. Depending on the damage, eye pain, lid swelling, ecchymosis, and decreased visual acuity may also occur.

Parinaud’s syndrome

This form of ophthalmoplegia can cause ptosis, enophthalmos, nystagmus, lid retraction, dilated pupils with absent or poor light response, and papilledema. The patient’s ocular muscles fail to move voluntarily.

Parry-Romberg syndrome

Unilateral ptosis and facial hemiatrophy occur with this disorder. Other signs include miosis, sluggish pupil reaction to light, enophthalmos, different-colored irises, ocular muscle paralysis, nystagmus, and neck, shoulder, trunk, and extremity atrophy.

Subdural hematoma (chronic)

Ptosis may be a late sign, along with unilateral pupillary dilation and sluggishness. Headache, behavioral changes, and decreased LOC commonly occur.

Other causes

Drugs

Vinca alkaloids can produce ptosis.

Lead poisoning

With this disorder, ptosis usually develops over 3 to 6 months. Other findings include anorexia, nausea, vomiting, diarrhea, colicky abdominal pain, a lead line in the gums, decreased LOC, tachycardia, hypotension and, possibly, irritability and peripheral nerve weakness.

Special considerations

If the patient has decreased visual acuity, orient him to his surroundings. Provide special spectacle frames that suspend the eyelid by traction with a wire crutch. These frames are usually used to help patients with temporary paresis or those who aren’t good candidates for surgery.

Prepare the patient for diagnostic studies, such as the Tensilon test and slit-lamp examination. If he needs surgery to correct levator muscle dysfunction, explain the procedure to him.

Pediatric pointers

Astigmatism and myopia may be associated with childhood ptosis. Parents typically discover congenital ptosis when their child is an infant. Usually, the ptosis is unilateral, constant, and accompanied by lagophthalmos, which causes the infant to sleep with his eyes open. If this occurs, teach proper eye care to prevent drying.

Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.

More About Causes of Eyelid symptoms

• Back to symptom: Eyelid symptoms: Introduction (review 664 causes)
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More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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