Ptosis for PACES (2)

Axonopathic, thank you for your comment. Ptosis with normal pupils is worth for a special discussion. What is the differential diagnosis? The clue starts from the moment you shake the patient's hand!

1. Myotonic dystrophy
* Bilateral ptosis
* Myotonia with hatchet look
* Wasting of temporalis, facial muscles, masseter, sternomastoids

Myopathic facies
2. Myasthenia gravis
* Unilateral/bilateral ptosis
* Fatiguibility
* Variable strabismus/diplopia
* Bulbar symtoms (though not all)

MG patient in respiratory distress

3. Facioscapulohumeral dystrophy
* Bilateral ptosis
* Wasting of facial muscles,sternomastoids and limb-girdle muscles.
* Winging of scapula
* Foot drop - classical case has weakness of anterior tibialis


Foot drop
4. Chronic Progressive External Ophthalmoplegia(Kearns-Sayre Syndrome)
* Bilateral ptosis
* Symmetric ophthalmoplegia
* Look for retinitis pigmentosa



Bilateral ptosis with severely decreased motility in all directions of gaze

5. Oculopharyngeal muscular dystrophy
*Scenario may suggest history of dysphagia
*Extraocular weakness
*Distal limb weakness