Ptosis - Differential Diagnosis Framework Ptosis (Greek- to fall) Drooping of the upper eyelid that usually results from a congenital or acquired abnormality of the muscles that elevate the eyelid. When patients present with ptosis, it is important to think about three clinical diagnoses associated with ptosis: 1. CN III palsy 2. Horner’s syndrome 3. Myasthenia gravis Neurogenic Ptosis - Neurologic disease affecting the muscle, neuromuscular junction, cranial nerve, and the brainstem may lead to ptosis and weakness of the levator muscle of the upper eyelid: • Third nerve palsy • Horner syndrome • Myasthenia gravis • Botulinum toxin • Multiple sclerosis • Cerebral ptosis - Supranuclear lesions • Ophthalmoplegia migraine Myogenic Ptosis: • Mitochondrial myopathy • Myotonic dystrophy • Myasthenia gravis • Ocular myopathy • Oculopharyngeal muscular dystrophy • Blepharophimosis syndrome Aponeurotic Ptosis: • Spontaneous disinsertion or dehiscence of the levator aponeurosis (the tendon connecting the levator to the tarsal plate) • Involutional (senile) change • Contact lens wearing • Ocular surgery Congenital Ptosis - Absence or reduction of striated levator palpebrae superioris muscle: • Marcus Gunn jaw-winking syndrome Traumatic Ptosis - Direct or indirect trauma to the eyelid leading to: • Levator transection • Cicatrization • Eyelid laceration or orbital rooftop fracture with ischemia Mechanical Ptosis - Levator function is impaired due to the mass effect of some abnormal external structure/excess weight on the upper lid: • Neoplasm • Chalazion • Contact lens in the upper fornix • Scarring • Ocular pemphigoid • Trachoma Pseudoptosis: • Microphthalmos • Anophthalmos • Enophthalmos • Lid retraction of one eye causing ptosis in the contralateral eye • Redundant eyelid skin and prolapse of the orbital fat (dermatochalasis) • Lowering the ipsilateral eyebrow and raising the contralateral one • Duanes Syndrome #Ptosis #neurology #Differential #Diagnosis #ophthalmology #ocular
