2. Case History
Name- xxxx
Age/sex- 41 yrs/ F
Occupation- Housewife
Complaints-
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 eyelid
BE- c/o gradual decrease in distance vision x
2 months
RE- No other specific ocular complaints
August 30, 2015
Case report
2
3. Previous ocular history-
No h/o glasses wear
No h/o surgery and trauma
General health-
No h/o DM and HTN
h/o botulinum toxin injection used for cosmetic
purpose
Family history-
Not contributory
Recent investigation-
Nil
Current treatment-
Nil
Allergy-
Not aware of any
August 30, 2015
Case report
3
4. 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 cms
RE- N6
LE- N6
August 30, 2015
Case report
4
5. Refraction-
Objective refraction
RE- +0.25 DS/ -1.00 DC x 100
LE- ±/ -0.50 DC x 90
Subjective refraction
RE- ±/ -0.75 DC x 100 (6/6)
LE- ±/ -0.50DC x 80 (6/6)
Duochrome-
RE- Balanced
LE- Balanced
JCC-
BE- JCC refined
August 30, 2015
Case report
5
9. Ptosis evaluation
Head posture
Normal
Palpebral fissure height
RE- 7.5 mm
LE- 11 mm
Marginal reflex distance(MRD)-1
RE- 2.5 mm
LE- 5.5 mm
August 30, 2015
Case report
9
10. Marginal reflex distance(MRD)-2
RE- 5 mm
LE- 5.5 mm
Margin crease distance (MCD)-
RE- 8 mm
LE- 8.5 mm
Levator function-
RE- 11 mm
LE- 14 mm
August 30, 2015
Case report
10
11. Margin limbal distance-
RE- 8 mm
LE- 10 mm
Bell’s phenomenon-
RE- present
LE- present
Corneal sensitivity-
RE- present
LE- present
August 30, 2015
Case report
11
13. Frontalis overaction
RE- Absent
LE- Absent
Cogan lid twitch test-
RE- Negative
LE- Negative
10% phenylephrine test:
RE- improves by 2mm
LE- same as before
August 30, 2015
Case report
13
14. Slit lamp examination
ptosis
normal
Conjunctiva-
normal
Cornea-
normal
Pupils- RTL
Lens- normal Lens- normal
RE LE
August 30, 2015
Case report
14
16. Diagnosis-
mild ptosis
Advice-
ptosis crutch
follow up after 6 months
August 30, 2015
Case report
16
17. 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
August 30, 2015
Case report
17
18. b. 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
August 30, 2015
Case report
18
19. Clinical manifestation
Symptoms
Asymptomatic if pupil is not covered
Visual disturbance if pupil is covered
Cosmetic disfigurement
Diplopia
Abnormal head posture and head tilt
August 30, 2015
Case report
19
20. 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
August 30, 2015
Case report
20
21. 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
August 30, 2015
Case report
21
22. Palpebral fissure height-
Margin reflex distance(MRD)-1
August 30, 2015
Case report
22
23. Margin reflex distance(MRD)-2
Distance between lower lid margin and pupillary
reflex
Margin crease distance-
August 30, 2015
Case report
23
24. Levator function-
Margin limbal distance-
Distance from middle of upper eyelid to inferior
limbus
August 30, 2015
Case report
24
27. Normal values
Tests 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 13-17mm
Margin limbal distance 9mm
Bell’s phenomenon Upward rotation of eyeball
with closure of eyelid
August 30, 2015
Case report
27
28. 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.
August 30, 2015
Case report
28
31. 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
August 30, 2015
Case report
31