This document summarizes a medical case of a 21-year-old male student who was born with drooping of his left eyelid. Upon examination, the doctor notes that the patient has unilateral drooping of the left eyelid since birth with no double vision or other symptoms. Various tests were performed including visual acuity tests and eyelid measurements, which confirmed ptosis, or drooping, of the left upper eyelid since birth with normal function and vision in both eyes otherwise. The doctor's assessment is that the patient has a simple congenital ptosis, or drooping eyelid, of the left eye.

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