May 3, 2023

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Case ReportBy Sameep Adhikari

May 3, 2023

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Case HistoryName- xxxxAge/sex- 41 yrs/ FOccupation- HousewifeComplaints-

RE- c/o unilateral drooping of upper eyelid that varies during the day and aggravated after use of Botulinum toxin injection x 4 months

LE- No c/o drooping of eyelidBE- c/o gradual decrease in distance vision x 2 monthsRE- No other specific ocular complaints

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3Previous ocular history-No h/o glasses wearNo h/o surgery and trauma

General health-No h/o DM and HTNh/o botulinum toxin injection used for cosmetic

purposeFamily history-

Not contributoryRecent investigation-

NilCurrent treatment-

NilAllergy-

Not aware of any

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Ocular examination Visual Acuity-Distance visual acuity with snellen chart (U/A)

RE- 6/9 PH 6/6p (upper eyelid uplifted)LE- 6/9 PH 6/6

Near visual acuity with continuous text chart @ 38 cmsRE- N6LE- N6

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5 Refraction- Objective refraction

RE- +0.25 DS/ -1.00 DC x 100LE- ±/ -0.50 DC x 90

Subjective refractionRE- ±/ -0.75 DC x 100 (6/6)LE- ±/ -0.50DC x 80 (6/6)

Duochrome- RE- BalancedLE- Balanced

JCC-BE- JCC refined

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6 Keratometer

RE- 45.00D@V [7.5mm] 44.00D@H[7.67mm]LE- 45.5D@V[7.41mm]

45.00D@H[7.5mm] Extra ocular motility-

0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 RE- SAFE LE- SAFE

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Hirschberg test-ortho

Pupils-RE- PERRLALE- PERRLANo RAPD

Colour vision with Ishihara plates @75 cmsRE- 25/25 (correct response)LE- 25/25 (correct response)

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Confrontation-RE-

within normal limitsLE-

within normal limits

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Ptosis evaluation Head posture

Normal Palpebral fissure height RE- 7.5 mm

LE- 11 mm Marginal reflex distance(MRD)-1

RE- 2.5 mmLE- 5.5 mm

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10 Marginal reflex distance(MRD)-2

RE- 5 mmLE- 5.5 mm

Margin crease distance (MCD)-RE- 8 mmLE- 8.5 mm

Levator function-RE- 11 mmLE- 14 mm

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11 Margin limbal distance-

RE- 8 mmLE- 10 mm

Bell’s phenomenon-RE- presentLE- present

Corneal sensitivity-RE- presentLE- present

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12 Fatigue test-

RE- positiveLE- positive

Tensilion test-RE- absentLE- absent

Marcus Gunn jaw winking phenomenon-RE- absentLE- absent

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13 Frontalis overaction

RE- AbsentLE- Absent

Cogan lid twitch test-RE- NegativeLE- Negative

10% phenylephrine test:RE- improves by 2mmLE- same as before

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14 Slit lamp examination

ptosisnormal

Conjunctiva- normal

Cornea- normal

Pupils- RTL

Lens- normal Lens- normal

RE LE

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15 Fundus examination

Retina- ON

FR+

Cdr- normal

RE LE

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Diagnosis-mild ptosis

Advice-ptosis crutch follow up after 6 months

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Ptosis Abnormal drooping of upper eyelid Classification of ptosis Congenital ptosis Acquired ptosis

a. Myogenic ptosis- caused by myopathy of levator function or impaired transmission of impulses at neuromuscular junction Seen in case of myasthenia gravis, myotonic

dystrophy and LPS muscle trauma

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18b. Neurogenic ptosis- caused by

innervational defect such as third nerve palsy or Horner’s syndrome

c. Aponeurotic ptosis- caused by defect in levator aponeurosis such as senile or postoperative cases

d. Mechanical ptosis- caused due to excessive weight on upper eyelid like as in eyelid tumours, scars and chalazion

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Clinical manifestation Symptoms Asymptomatic if pupil is not covered Visual disturbance if pupil is covered Cosmetic disfigurement Diplopia Abnormal head posture and head tilt

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Signs Narrow palpebral fissure height Absence of upper eyelid crease in case of

congenital ptosis Frontalis overaction Backward head tilt Signs related to underlying cause

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Clinical evaluation of ptosis History taking- Age of onset Aggravating or alleviating factors Variation in amount of ptosis during the

day Associated with diplopia, abnormal head

posture

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22 Palpebral fissure height-

Margin reflex distance(MRD)-1

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23 Margin reflex distance(MRD)-2 Distance between lower lid margin and pupillary

reflex Margin crease distance-

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24 Levator function-

Margin limbal distance- Distance from middle of upper eyelid to inferior

limbus

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25 Bell’s phenomenon-

Corneal sensitivity-

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Frontalis overaction

Marcus-Gunn jaw winking phenomenon

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Normal valuesTests done for ptosis evaluation

Normal values

Palpebral fissure height 7-10mm(male)8-12mm(female)

Margin reflex distance(MRD)1

4-5mm

Margin reflex distance(MRD)2

>5mm

Lid crease height 5-7mm(male)8-10mm(female)

Levator function 13-17mmMargin limbal distance 9mmBell’s phenomenon Upward rotation of eyeball

with closure of eyelid

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Tensilion test-1 mg of neostigmine is injected in a

patient.In case of Myasthania gravis, ptosis

improves in 5-10 minutes

Cogan lid twitch test-Patient is asked to look downwards and

then in primary position quickly. The upper eyelid retracts and then droops slowly to ptotic condition.

Positive result suggests of Myasthania gravis in patient.

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Pseudoptosis

Right pseudoptosis due to artificial eye

Brow ptosis

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Dermatochalasis

Left pseudoptosis due to contralateral eyelid retraction

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Management

Ptosis crutches- to hold the upper eyelid to avoid eyelid to cover the pupil

Treat the underlying causes Surgery – Tarso-conjunctivo-

Mullerctomy(Fasanella-servat operation) Levator resection Frontalis sling operation

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Thank you…