Ptosis case presentation

1. DR.ANKITA MAHAPATRA
DEPT. OF OPHTHALMOLOGY
VSSIMSAR, BURLA

2.  21 Yr /HM
 Sundargarh
 Student
CHIEF COMPLAINT :
Drooping of eyelid (LE) – since birth

3.  Patient has unilateral drooping of eye lid of Left eye since birth.
 Constant through out the day
 Not complaining of double vision

4.  No aggravating or relieving factor
 No H/o trauma
 No h/o any previous surgery
 No h/o contact lens wear
 No h/o botox injection
 No h/o any drug intake or poisoning
 No h/o Myasthenia gravis , myotonia , Muscular dystrophy , Diabetes,
HTN
 No h/o recurrent stye/ chalazion / vernal keratoconjunctivitis

5.  From a middle socioeconomic background
 Normal bowel and bladder habit
 Normal non vegetarian Indian diet
 Allergic history not known
 Family history not suggestive

6.  Average body built, well nourished
 Conscious & Well oriented to time, place and person
 No cyanosis, icterus, pallor , clubbing , pedal oedema or
lymphadenopathy
 Vitals
 PR- 78/min
 B.P -120/90 mm of Hg
 R.R- 14/min
 Temp- 98.4°F

7.  CNS :- Conscious, Oriented, GCS – 15
 CVS:- S1, S2 normal, no murmur
 RS:- B/L VBS, No added sounds
 P/A :- Soft, Non tender, No organomegaly

8.  Head is erect, slight back tilt present
 Drooping of Left upper eye lid
 Absence of Left upper eyelid crease
 Orthophoric
 EOM – free, full, painless in all directions of gaze
 BCVA :-
RE- 6/6
LE – 6/6 (Upper eyelid uplifted)
 Near vision – N6 (BES)

10. OD OS
Lid and adnexa Normal Drooping of upper eyelid
Conjunctiva Normal Normal
Cornea Clear
Corneal sensation intact
Clear
Corneal sensation intact
Ant. Chamber PACD = 1CT PACD = 1CT
Iris and Pupil Normal in colour and pattern,
Pupil- Circular, reacting to light
Normal in colour and pattern,
Pupil- Circular, reacting to light
Lens Clear Clear

11. TESTS DONE OD OS
PALPEBRAL FISSURE HEIGHT 10 mm 6 mm
MARGIN REFLEX
DISTANCE(MRD)1
5 mm -1 mm
MARGIN REFLEX
DISTANCE(MRD)2
5mm 5mm
MARGIN CREASE DISTANCE 9 mm Absent
LPS FUNCTION (BERKE’S
METHOD
12 mm 3 mm (poor)
LPS FUNCTION (PUTTERMAN’S
METHOD)
9 mm 6mm

12.  Bell’s phenomenon- Good in both eyes
 No Lagophthalmos
 No Diplopia
 Marcus-Gunn jaw winkingphenomenon absent
 Cogan lid twitch test- absent
 Shirmer’s test – normal
 No signs of any Keratopathy

13. OD OS
Mydriasis Good Good
Media clear Clear
Optic Disc Normal Normal
Macula FR+ FR+
Blood vessel Normal Normal
Periphery Normal Normal

14. SIMPLE CONGENITAL PTOSIS( LEFT EYE )

15. THANK YOU