Neuro-ophthalmology Question of the Week: Emergency Department Evaluation of Ptosis


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)
     Arrange neuro-­ophthalmology appointment
    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
            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.
                     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
                           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


Video Cogan’s Lid Twitch 

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
4.  Ptosis due to myasthenia with contralateral lid retraction.

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