Ptosis (F)

Question 1

What should be done if there is a ptosis with no pupil abnormality?

Answer 1

1. look for signs of myasthenia gravis

2. If no MG then look for Chronic progressive external ophthalmoplegia (CPEO) or myotonic dystrophy

Question 2

What does ptosis with ipsilateral pupil dilated with decreased reactivity suggest?

Answer 2

third nerve palsy

Question 3

What is the management of congenital ptosis?

Answer 3

observe unless covers pupil (amblyopia)

Question 4

What is the cause of congenital ptosis? 1. What is a key sign of this? 2

Answer 4

1. failure of LPS to differentiate

2. when look down, eye with ptosis is higher; inadequate Bell’s phenomenon

Question 5

What are the potential cause of ptosis if no pupillary involvement and no MG signs?

Answer 5

1. CPEO
2. myotonic dystrophy
3. Fisher’s variant of Guillain-Barre syndrome
4. Myasthenia gravis with false negative on Tensilon test
5. cranial nerve involvement, eg. pupil-sparing CN III paresis

Question 6

What are examples of pseudoptosis?

Answer 6

1. blepharospasm
2. dermatochalasis
3. retraction of contralateral lid
4. vertical eye deviation
5. lack of support from globe (enophthalmos, microophthalmia, phthisis bulbi)

Question 7

What are the signs of Chronic progressive external ophthalmoplegia (CPEO)?

Answer 7

bilateral and progressive with EOM involvement

Question 8

What does ptosis with ipsilateral miosis suggest?

Answer 8

Horner syndrome

Question 9

What is the ptosis that improves with contraction of masseter muscle called? 1. What is the management? 2

Answer 9

1. Marcus-Gunn or jaw winking phenomenon

2. no neuro eval needed, possibly surgery for ptosis

Question 10

What does ptosis with large pupil with sphincter tears/ruptures observed on biomicroscopy suggest?

Answer 10

trauma or surgery

Question 11

How do you determine if a patient has vertical muscle imbalance leading to a pseudoptosis?

Answer 11

measure palpebral fissure with each eye fixating (should be equal)

Question 12

What is the most common cause of acquired ptosis? 1. What are the signs? 2

Answer 12

1. aponeurotic (levator dehiscence)

2. high skin crease, deeper superior lid sulcus, ptotic lid lower than normal lid in up and down gaze

Question 13

What are the signs of myotonic dystrophy?

Answer 13

1. christmas tree cataract
2. inability to release muscles after action (shake hand and difficulty releasing)
3. family history