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…
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