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Home , Miosis, Ptosis (eyelid)

TEST YOUR KNOWLEDGE: Eye series

Droopy Eye series 2

A 75 year old man presented to the practice complaining of an increasingly droopy eyelid over the past 12 months. It appears worse toward the end of the day when he is tired. He is on no current and has had no previous . reactions are normal and no abnormalities are noted on ocular movement examination.

Chris Hodge, BAppsc, DOBA, is Research Director, The Eye Institute, Chatswood, New South Wales. Peter A Martin, FRANZCO, FRACS, is an Oculoplastic Surgeon, Harley Place, Bondi Junction, and The Eye Institute, Chatswood, New South Wales.

Question 1 Answers

What clinical features will help lead to a Answer 1 possible neurological changes. Close diagnosis? ocular examination is essential. Lid A concise history is essential. The patient muscle (levator) function, pupil and extra Question 2 history will provide important clues to the ocular movement testing will provide pos- What are the differential diagnoses? aetiology of the condition. ‘Droopy itive clues to the aetiology. Lid position in ’ or can be classified as primary and downgaze is also important Question 3 either congenital or acquired. to note. What is your final diagnosis? Furthermore, ptosis can be subclassified as aponeurotic, myogenic, neurogenic, Answer 2 Question 4 traumatic or mechanical in origin. Differential diagnoses may include a Would you request further diagnostic Classification will aid the differential defect in the aponeurosis of the levator tests, and if so, which tests? diagnosis of the condition and ultimately muscle, Horner’s syndrome, partial or determine treatment options. General full-third palsy, ocular myopathy Question 5 health and in particular, previous eye and . What factors will influence the course of history, should be noted. Horner’s syndrome is usually charac- treatment? Once the ptosis is determined as acquired, terised by minimal ptosis changes, , further questioning is necessary. The enopthalmos and anhydrosis. Third nerve duration and progression of the condition palsies will also likely have pupil changes is vital. Family photos may be a useful aid concurrent with the ptosis. A full-third in pin-pointing origin and change. The nerve palsy will represent a complete presence of associated symptoms such as ptosis of the upper eyelid. and double vision, , or jaw possibly double vision may also be winking will also serve to assist diagnosis present when the lid is raised. and future management. Ocular myopathies are usually symmetrical Observation of facial expression, tone of in nature and are often associated with other voice and gait will provide clues of any broad changes such as muscle weakness.

Reprinted from Australian Family Physician Vol. 32, No. 3, March 2003 • 1 n Droopy eyelid

Poor or no ocular movements, especially Answer 5 during later stages are common findings. Often the patient will complain of Myasthenia gravis is relatively uncommon. increasing ptosis which may interfere with Variable ptosis and are usually the superior field of vision especially later the initial and common traits of this condi- in the day. Similarly the patient may tion. Fatigability of the ptosis is also a mention that afternoon or night time distinguishing feature. This condition is reading becomes tiresome causing further confirmed by an increase in strength fol- asthenopic symptoms. lowing an injection of edrophonium If symptoms persist surgery may be indi- chloride into the lid (Tensilon test). cated. Surgery in aponeurotic cases is Answer 3 successful in approximately 85% of cases. Treatment is aimed at restoring cosmesis The ptosis is asymmetrical. There are no and symmetry to the eyelids. Adequate signs of extra ocular muscle or pupil anom- lid function and blink without producing alies. General health is good. There is no complications such as lid notching or dis- previous history of eyelid trauma or surgery. tortion is also important. The patient is likely to have dehiscence of The absence of Bells phenomenon in the levator aponeurosis. The aponeurotic which the eye rolls up into the when ptosis is characterised by varying ptosis, the lid closes, increases the risk of corneal worsening at the end of the day (as exposure therefore a modified surgical Müller muscle ). A higher skin and postoperative approach is necessary. crease of the affected eyelid and deeper upper sulcus (or recess of the eyelid) is Further reading seen on examination. Commonly an 1. Martin P A. Management of the ptosis increased translucency of the eyelid can patient. Modern Medicine 1992; also be noticed. 11:38–47. 2. Martin P A, Rogers P A. Congenital The most common cause is involutional aponeurotic ptosis. Aust N Z J Ophthalmol changes in which the aponeurosis muscle 1988; 16:291–294. stretches over time and areas of dehis- 3. Fujiwara T, Matsuo K,Kondoh S, Yuzuriha S. Etiology and pathogenesis of aponeu- cence occurs, therefore it is relatively rotic blepharoptosis. Ann Plast Surg 2001; common in the older population. These 46(1):29–35. changes though can also occur due to 4. Oosterhuis H J. Acquired blepharoptosis. Clin Neurol Neurosurg 1996; 98(1):1–7. chronic of the eyelid and 5. Kersten R C, de Conciliis C, Kulwin D R. through contact use, especially in Acquired ptosis in the young and middle cases of hard or rigid use. aged adult population. 1995; 102(6):924–928. Excessive rubbing of the eyelids has also AFP been listed as a contributing cause.

Answer 4 Because of the diagnosis no further exter- nal tests are required although a drop of phenylephrine (2.5%) will correct the ptosis and confirm the diagnosis. Muscle function testing, X-ray or MRI scans may be useful in those situations where diag- nosis is in doubt. However, these are expensive tests and should only be used when necessary.

2 • Reprinted from Australian Family Physician Vol. 32, No. 3, March 2003