Ptosis Revisited

eMRCPian has done a great job describing ptosis in the April posting. I'm trying my best to further describe all the important causes of ptosis.

En. Ramli, 30 year old gentleman was told by his friends that he has abnormal eyes. Please examine the eyes.

What’s the Dx?

PTOSIS

*An unequal bilateral ptosis could be easily mistaken to be a unilateral ptosis.

Inspect

Dystrophia myotonica look ( suspect during hand shake)
Eye looking downward and outward

Look at the pupils

-dilated in surgical 3rd nerve palsy
i. isolated: PCOM aneurysm( check hemiplegia, cerebellar, extrapyramidal signs)
ii. III, IV, V1, VI CN–superior orbital fissure synd( II involved)/cavernous sinus thrombosis

-constricted in Horner's syndrome (common: Pancoast tu, LMS)
i. V, IX, X ( LMS)
ii. Neck ( inspect for scars, thyroid; palpate for LN; auscultate for carotid aneurysm
iii. Percuss Upper zone- Pancoast
iv. UL - small muscle wasting, pronator drift ( MS, syringomyelia)
sensation
cerebellar

-normal size pupil in MG, CPEO, dystrophy myotonica, Miller Fisher, medical 3rd nerve( DM, H/T, vasculitis)
i. Eyes
1. Fatigability- upward gaze
2. VARIABLE Strabismus and diplopia in MG( no particular CN opthalmoplegia).
Medical 3rd nerve palsy?

ii. Face
1. V CN
2. VII CN
3. Bulbar ( count 1-50)

iii. Muscle
1. Neck Flexion
2. Proximal myopathy
3. Reflex ( ELS, Miller Fisher)

Look for
1) Treatment given: median sternotomy , subclavian line
2) Complication: tracheostomy, gastrostomy
3) Fundus ( CPEO)
4) Ass A/I dis


Ix for MG:
FVC, Edrophonium test, Anti Acetylcholine receptor Ab, EMG, CXR, CT mediastinum

Tx:
Long acting cholinesterase inhibitor
Thymectomy