⁴

a. Photograph of the patient showing right partial ptosis. The left lid shows compensatory lid retraction because of equal innervation of the levator palpabrae superioris (Herring’s law).
b. Post tensilon test: Note the improvement in ptosis.

Question: Describe the appropriate steps to take  in the emergency department when evaluating  ptosis of recent onset.

__________________________________________

ED Concerns – Aneurysm (3rd nerve paresis), Horner syndrome, Myasthenia, Guillian-Barre (Fisher variant), Botulism

ED Ptosis Evaluation
Assess for Pseudoptosis  
   Apraxia of lid opening (motor neuron, hemispheric and extrapyramidal disease)
Blepharospasm
Hypertropia
     ● Arrange neuro-­ophthalmology appointment
    Dermatochalasis
    Contralateral lid retraction
Hyperglobus ­
      ● Arrange oculoplastics appointment

True Ptosis
    Lid deformity = Tumor, infection, chalazion, “lost” but retained contact lens, trauma
      ● Arrange oculoplastics appointment
    No lid deformity
        Onset at birth = Congenital ptosis, Myopathies, Jaw­-winking phenomenon
           ● Arrange pediatric ophthalmology appointment
        Acquired
            Topical steroid use = corticosteroid induced ptosis
                 ● Arrange oculoplastics appointment
        No Topical steroid use
             Pupillary Abnormality Present
                 3rd nerve palsy
                 Horner syndrome
                    ● Arrange emergent MRI of appropriate locations
                 Guillain ­Barre (Miller ­Fisher variant) Pupils may be dilated, without light or near reflex or have tonic reaction.
                 Botulism
                     ● Neurology consultation
                 Traumatic iridoplegia
                     ● Arrange ophthalmology clinic follow-­up
           Pupil Normal
                  Check Fatigue of Eyelid Elevation, Cogan Lid Twitch & Rest/Ice Pack Test
                        Positive consider myasthenia gravis
                            ● Order Myasthenia gravis adult antibody screening panel
                            ● Neurology consultation
                        Negative
                           Associated neurologic signs
                              ● Brain & Orbit MRI with and without contrast
                                ● Neurology consultation
                           No associated neurologic signs
                               Idiopathic “senile” ptosis (levator disinsertion or dehiscence)
                                ● Arrange oculoplastics appointment

From: Clinical Pathways in Neuro-ophthalmology 2003²

³

Video Cogan’s Lid Twitch 

References:
1. Clinical Decisions in Neuro-Ophthalmology,  Burde RM, Savino PJ & Trobe JD. 3nd Edition. Mosby 2002
2. Clinical Pathways in Neuro-ophthalmology:An Evidence-Based Approach. Lee AC & Brazis PW. Thieme 2003
3. Cogan’s Lid Twitch Video  http://www.kaltura.com/index.php/extwidget/preview/partner_id/797802/uiconf_id/27472092/entry_id/0_u9tn4w8i/embed/auto?
4.  Ptosis due to myasthenia with contralateral lid retraction. https://commons.wikimedia.org/wiki/File:Myasthenia_gravis_ptosis_reversal.jpg

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